1396793634 NPI number — EMORY L OTTO PSY.D.

Table of content: EMORY L OTTO PSY.D. (NPI 1396793634)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396793634 NPI number — EMORY L OTTO PSY.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OTTO
Provider First Name:
EMORY
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PSY.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396793634
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/05/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1001 E OREGON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITITZ
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17543-9205
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-581-3976
Provider Business Mailing Address Fax Number:
717-509-5410

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
433 S KINZER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW HOLLAND
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17557-8736
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-581-3976
Provider Business Practice Location Address Fax Number:
717-509-5410
Provider Enumeration Date:
05/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TH0100X , with the licence number:  PS005174L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X , with the licence number: PS005174L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 180496 . This is a "VALUE OPTIONS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 45733215 . This is a "UNITED BEHAVIORAL HEALTH" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 166182 . This is a "HIGHMARK PERSONAL CHOICE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: OT582253 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 02792700 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1697570 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 227252000 . This is a "MAGELLAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 4478017 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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