Provider Demographics
NPI:1396793634
Name:OTTO, EMORY L (PSYD)
Entity type:Individual
Prefix:
First Name:EMORY
Middle Name:L
Last Name:OTTO
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 E OREGON RD
Mailing Address - Street 2:
Mailing Address - City:LITITZ
Mailing Address - State:PA
Mailing Address - Zip Code:17543-9205
Mailing Address - Country:US
Mailing Address - Phone:717-581-3976
Mailing Address - Fax:717-509-5410
Practice Address - Street 1:433 S KINZER AVE
Practice Address - Street 2:
Practice Address - City:NEW HOLLAND
Practice Address - State:PA
Practice Address - Zip Code:17557-8736
Practice Address - Country:US
Practice Address - Phone:717-581-3976
Practice Address - Fax:717-509-5410
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS005174L103TH0100X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA180496OtherVALUE OPTIONS
PA45733215OtherUNITED BEHAVIORAL HEALTH
PA166182OtherHIGHMARK PERSONAL CHOICE
PAOT582253OtherBLUE SHIELD
PA02792700OtherCAPITAL BLUE CROSS
PA1697570Medicaid
PA227252000OtherMAGELLAN
PA4478017OtherAETNA
PARO7453Medicare UPIN