Provider Demographics
NPI:1457116667
Name:OTORI, MATTIE FREDERICK
Entity Type:Individual
Prefix:
First Name:MATTIE
Middle Name:FREDERICK
Last Name:OTORI
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 1:28043 BURRO SPRINGS LN
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77386-4230
Mailing Address - Country:US
Mailing Address - Phone:337-654-7487
Mailing Address - Fax:
Practice Address - Street 1:28043 BURRO SPRINGS LN
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77386-4230
Practice Address - Country:US
Practice Address - Phone:337-654-7487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-16
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX107766235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist