Provider Demographics
NPI:1700584653
Name:OTTER, OLIVIA RAE (DPT, PT)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:RAE
Last Name:OTTER
Suffix:
Gender:F
Credentials:DPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 COREY LN
Mailing Address - Street 2:
Mailing Address - City:NIANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06357-1335
Mailing Address - Country:US
Mailing Address - Phone:860-694-9834
Mailing Address - Fax:
Practice Address - Street 1:100 PERKINS FARM DR STE 202
Practice Address - Street 2:
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-4041
Practice Address - Country:US
Practice Address - Phone:860-572-5455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-20
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT013202225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist