Provider Demographics
NPI:1982042230
Name:OTIS, MINDY (PHD)
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:
Last Name:OTIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 FARMINGTON AVE
Mailing Address - Street 2:#309
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-1909
Mailing Address - Country:US
Mailing Address - Phone:860-677-5570
Mailing Address - Fax:860-677-9570
Practice Address - Street 1:270 FARMINGTON AVE
Practice Address - Street 2:#309
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-1909
Practice Address - Country:US
Practice Address - Phone:860-677-5570
Practice Address - Fax:860-677-9570
Is Sole Proprietor?:No
Enumeration Date:2013-06-10
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001778103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical