Provider Demographics
NPI:1801116520
Name:OTT, MAXA
Entity type:Individual
Prefix:DR
First Name:MAXA
Middle Name:
Last Name:OTT
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 1:595 E COLORADO BLVD
Mailing Address - Street 2:SUITE 332
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-2039
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:595 E COLORADO BLVD
Practice Address - Street 2:SUITE 332
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-2039
Practice Address - Country:US
Practice Address - Phone:626-449-3045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-03
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC32747102L00000X
CAMFC34727106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist