Provider Demographics
NPI:1750612040
Name:OTT, SOPHIA LIN (PSYD)
Entity type:Individual
Prefix:DR
First Name:SOPHIA
Middle Name:LIN
Last Name:OTT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:650 N WINCHESTER BLVD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-1511
Mailing Address - Country:US
Mailing Address - Phone:408-457-1892
Mailing Address - Fax:408-457-8991
Practice Address - Street 1:650 N WINCHESTER BLVD
Practice Address - Street 2:SUITE 4
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1511
Practice Address - Country:US
Practice Address - Phone:408-457-1892
Practice Address - Fax:408-457-8991
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-26
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY23063103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical