Provider Demographics
NPI:1972641553
Name:OTT, KRISTIN LARA (PT, MPT)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:LARA
Last Name:OTT
Suffix:
Gender:F
Credentials:PT, MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7516 N SUMMIT VIEW DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-3025
Mailing Address - Country:US
Mailing Address - Phone:928-772-3925
Mailing Address - Fax:
Practice Address - Street 1:3195 STILLWATER DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-7171
Practice Address - Country:US
Practice Address - Phone:928-771-8156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3938225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ391772OtherAHCCCS NUMBER