Provider Demographics
NPI:1013503580
Name:ENOCH, OTIS
Entity Type:Individual
Prefix:
First Name:OTIS
Middle Name:
Last Name:ENOCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1936 S GRANDVIEW LN
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91792-1317
Mailing Address - Country:US
Mailing Address - Phone:818-566-3888
Mailing Address - Fax:
Practice Address - Street 1:1936 S GRANDVIEW LN
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91792-1317
Practice Address - Country:US
Practice Address - Phone:818-566-3888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-17
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11675235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist