MEDICARE: AMY OTTERSON LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	10532	NC

General Provider Information

NPI Number	:	1013349281
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY OTTERSON LPC

Provider Business Mailing Address
First Line	:	4721 BLACK MOUNTAIN PATH
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27612-8603
Country	:	US
Telephone Number	:	919-521-2178
Fax Number	:

Provider Business Practice Location Address
First Line	:	4721 BLACK MOUNTAIN PATH
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27612-8603
Country	:	US
Telephone Number	:	919-521-2178
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/30/2013
Last Update Date	:	02/11/2014

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