Provider Demographics
NPI:1295150860
Name:OTTO, LISA (LPCC)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:OTTO
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 OLD HARSHMAN RD
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:OH
Mailing Address - Zip Code:45431-1238
Mailing Address - Country:US
Mailing Address - Phone:937-237-4270
Mailing Address - Fax:
Practice Address - Street 1:4350 SCHWINN DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45404-1341
Practice Address - Country:US
Practice Address - Phone:937-237-4270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-19
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE3450101YM0800X
OHOH1463726101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health