1578889184 NPI number — COURTNEY ANN OTTESON LSW

Table of content: COURTNEY ANN OTTESON LSW (NPI 1578889184)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578889184 NPI number — COURTNEY ANN OTTESON LSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OTTESON
Provider First Name:
COURTNEY
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LSW
Provider Gender Code:
F

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:
1578889184
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
519 2ND STREET N
Provider Second Line Business Mailing Address:
INDEPENDENT LIFESTYLES, INC
Provider Business Mailing Address City Name:
ST. CLOUD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-529-9000
Provider Business Mailing Address Fax Number:
320-529-0747

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
519 2ND ST N
Provider Second Line Business Practice Location Address:
INDEPENDENT LIFESTYLES
Provider Business Practice Location Address City Name:
ST. CLOUD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-529-9000
Provider Business Practice Location Address Fax Number:
320-529-0747
Provider Enumeration Date:
04/08/2010

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: 104100000X , with the licence number:  18899 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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