Provider Demographics
NPI:1295936169
Name:OTT, MARIA LISA (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARIA
Middle Name:LISA
Last Name:OTT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6332 S JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80121-3646
Mailing Address - Country:US
Mailing Address - Phone:843-441-4128
Mailing Address - Fax:
Practice Address - Street 1:6332 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80121-3646
Practice Address - Country:US
Practice Address - Phone:843-441-4128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3064103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical