Provider Demographics
NPI:1992369813
Name:OTT, COURTNEY MICHELLE (LISW-S)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:MICHELLE
Last Name:OTT
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 GLENSHIRE LN
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-8165
Mailing Address - Country:US
Mailing Address - Phone:330-635-8637
Mailing Address - Fax:
Practice Address - Street 1:111 GLENSHIRE LN
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-8165
Practice Address - Country:US
Practice Address - Phone:330-635-8637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-25
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.15009871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical