Basic Information
| Provider Information | |||||||||
| NPI: | 1699955369 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OTT | ||||||||
| FirstName: | TONIE | ||||||||
| MiddleName: | SUE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7320 STATE HIGHWAY 108 | ||||||||
| Address2: | |||||||||
| City: | WAUSEON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435678200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193353732 | ||||||||
| FaxNumber: | 4193353462 | ||||||||
| Practice Location | |||||||||
| Address1: | 7320 STATE HIGHWAY 108 | ||||||||
| Address2: | |||||||||
| City: | WAUSEON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435678200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193353732 | ||||||||
| FaxNumber: | 4193353462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2007 | ||||||||
| LastUpdateDate: | 11/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S29513 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | S29513 | 01 | OH | OHIO SOCIAL BOARD | OTHER |