Provider Demographics
NPI:1376774281
Name:OTTO, NICOLE (LICSW)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:
Last Name:OTTO
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 CONNECTICUT AVE NW
Mailing Address - Street 2:300
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20008-1158
Mailing Address - Country:US
Mailing Address - Phone:202-624-0010
Mailing Address - Fax:
Practice Address - Street 1:2041 MARTIN LUTHER KING JR AVE SE
Practice Address - Street 2:239
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-7024
Practice Address - Country:US
Practice Address - Phone:202-610-0066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-27
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC500784111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical