Provider Demographics
NPI:1336526045
Name:OTTS, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:OTTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 W LODI AVE
Mailing Address - Street 2:SUITE G-2
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-3000
Mailing Address - Country:US
Mailing Address - Phone:209-334-2126
Mailing Address - Fax:209-369-8406
Practice Address - Street 1:1300 W LODI AVE
Practice Address - Street 2:SUITE G-2
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-3000
Practice Address - Country:US
Practice Address - Phone:209-334-2126
Practice Address - Fax:209-369-8406
Is Sole Proprietor?:No
Enumeration Date:2015-05-01
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)