MEDICARE: PAUL JOHN OTTKE LISW-S

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	I-8964-SUPV	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11576328	OTHER		CAQH #
2	000000246009	OTHER		ANTHEM PIN

General Provider Information

NPI Number	:	1952360117
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAUL JOHN OTTKE LISW-S

Provider Business Mailing Address
First Line	:	204 COOK RD
Second Line	:	SUITE 400
City	:	LEBANON
State	:	OH
Zip	:	45036-9600
Country	:	US
Telephone Number	:	513-228-7800
Fax Number	:	513-695-2952

Provider Business Practice Location Address
First Line	:	975 KINGSVIEW DR
Second Line	:	BLDG A
City	:	LEBANON
State	:	OH
Zip	:	45036-9562
Country	:	US
Telephone Number	:	513-228-7800
Fax Number	:	513-228-7846

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

Provider Enumeration Date	:	03/17/2006
Last Update Date	:	07/14/2015

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