Basic Information
| Provider Information | |||||||||
| NPI: | 1124477047 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCLAIN-OTTO | ||||||||
| FirstName: | MINDY | ||||||||
| MiddleName: | NOEL | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2795 FLORESTA DR NE | ||||||||
| Address2: | |||||||||
| City: | PALM BAY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329055522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3215084393 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2050 40TH AVE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | VERO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329682467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7725670061 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2016 | ||||||||
| LastUpdateDate: | 07/01/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SI2833 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.