Provider Demographics
NPI:1255875282
Name:OTTENWELLER, MATTHEW
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:OTTENWELLER
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 1:838 BARTON WOODS RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30307-1306
Mailing Address - Country:US
Mailing Address - Phone:720-365-7767
Mailing Address - Fax:
Practice Address - Street 1:4500 HUGH HOWELL RD STE 410
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4732
Practice Address - Country:US
Practice Address - Phone:404-594-2940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-09
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW006423104100000X
GACSW0061351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker