Provider Demographics
NPI:1336274190
Name:OTTO, LISA MICHELLE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MICHELLE
Last Name:OTTO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 VAUXHALL ST
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-5711
Mailing Address - Country:US
Mailing Address - Phone:860-442-2797
Mailing Address - Fax:860-701-3776
Practice Address - Street 1:7 VAUXHALL ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-5711
Practice Address - Country:US
Practice Address - Phone:860-442-2797
Practice Address - Fax:860-701-3776
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0053201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical