MEDICARE: JOHN OTT

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	1041C0700X	Clinical Social Worker	6801087431	MI

General Provider Information

NPI Number	:	1922686724
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN OTT

Provider Business Mailing Address
First Line	:	8272 FOREST LN
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-7721
Country	:	US
Telephone Number	:	231-632-5458
Fax Number	:	231-935-1929

Provider Business Practice Location Address
First Line	:	8272 FOREST LN
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-7721
Country	:	US
Telephone Number	:	231-632-5458
Fax Number	:	231-632-5458

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

Provider Enumeration Date	:	04/01/2021
Last Update Date	:	04/01/2021

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