Provider Demographics
NPI:1649257759
Name:OTT, BRIAN DESMOND (PHD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:DESMOND
Last Name:OTT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:41 BURNING BUSH DR
Mailing Address - Street 2:
Mailing Address - City:BOXFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01921-2713
Mailing Address - Country:US
Mailing Address - Phone:617-724-8235
Mailing Address - Fax:617-726-2894
Practice Address - Street 1:41 BURNING BUSH DR
Practice Address - Street 2:
Practice Address - City:BOXFORD
Practice Address - State:MA
Practice Address - Zip Code:01921-2713
Practice Address - Country:US
Practice Address - Phone:617-724-8235
Practice Address - Fax:617-726-2894
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3720103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA724788OtherTUFTS HEALTH PLAN
MAW03748OtherBCBS MA
MAW03748Medicare ID - Type Unspecified