Basic Information
| Provider Information | |||||||||
| NPI: | 1295102952 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OTT | ||||||||
| FirstName: | JOSHUA | ||||||||
| MiddleName: | GREGORY | ||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 207 W 3RD ST | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970581734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412965452 | ||||||||
| FaxNumber: | 5412962731 | ||||||||
| Practice Location | |||||||||
| Address1: | 207 W 3RD ST | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970581734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412965452 | ||||||||
| FaxNumber: | 5412962731 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2015 | ||||||||
| LastUpdateDate: | 12/22/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.