Provider Demographics
NPI:1992011217
Name:BREWER-OTTAN, ANGELIQUE SUZANNE (MS, LPC, NCC)
Entity Type:Individual
Prefix:MRS
First Name:ANGELIQUE
Middle Name:SUZANNE
Last Name:BREWER-OTTAN
Suffix:
Gender:F
Credentials:MS, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987-3405
Mailing Address - Country:US
Mailing Address - Phone:507-454-4341
Mailing Address - Fax:507-453-6267
Practice Address - Street 1:166 MAIN STREET
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987-3405
Practice Address - Country:US
Practice Address - Phone:507-454-4341
Practice Address - Fax:507-453-6267
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLPC00849101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional