Provider Demographics
NPI:1982611265
Name:OTTO, JUDITH A (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:A
Last Name:OTTO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12630 W NORTH AVE
Mailing Address - Street 2:BLDG E
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-4626
Mailing Address - Country:US
Mailing Address - Phone:262-785-1008
Mailing Address - Fax:262-432-9059
Practice Address - Street 1:12630 W NORTH AVE BLDG E
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005
Practice Address - Country:US
Practice Address - Phone:262-785-1008
Practice Address - Fax:262-432-9059
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI170-123104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39624700Medicaid