Basic Information
| Provider Information | |||||||||
| NPI: | 1447387345 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OTTEN | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | DREW | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LAADC, M-RAS, CSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1241 | ||||||||
| Address2: | |||||||||
| City: | MORRO BAY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934431241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054280288 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2180 JOHNSON AVE | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934014513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8057814861 | ||||||||
| FaxNumber: | 8057811227 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2007 | ||||||||
| LastUpdateDate: | 12/14/2015 | ||||||||
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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 | 101YA0400X | O0509301519 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | LCI0101214 | CA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.