Provider Demographics
NPI:1982954228
Name:OTT, CANDICE LYNELL (BA BHRS)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:LYNELL
Last Name:OTT
Suffix:
Gender:F
Credentials:BA BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 W ADA AVE
Mailing Address - Street 2:
Mailing Address - City:WILBURTON
Mailing Address - State:OK
Mailing Address - Zip Code:74578-2416
Mailing Address - Country:US
Mailing Address - Phone:918-297-3400
Mailing Address - Fax:918-297-3401
Practice Address - Street 1:113 W ADA AVE
Practice Address - Street 2:
Practice Address - City:WILBURTON
Practice Address - State:OK
Practice Address - Zip Code:74578-2416
Practice Address - Country:US
Practice Address - Phone:918-297-3400
Practice Address - Fax:918-297-3401
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor