Healthcare Provider Details

I. General information

NPI: 1932595394
Provider Name (Legal Business Name): MER OTIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2015
Last Update Date: 04/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4665 W LESSING LN
TUCSON AZ
85742-4439
US

IV. Provider business mailing address

4665 W LESSING LN
TUCSON AZ
85742-4439
US

V. Phone/Fax

Practice location:
  • Phone: 520-861-1331
  • Fax:
Mailing address:
  • Phone: 520-861-1331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number4155
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number4155
License Number StateMA

VIII. Authorized Official

Name: MS. MER OTIS
Title or Position: PRINCIPAL
Credential:
Phone: 520-861-1331