Healthcare Provider Details

I. General information

NPI: 1619681251
Provider Name (Legal Business Name): EDMOND L OTIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2023
Last Update Date: 01/09/2023
Certification Date: 01/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26449 BODEGA CT
MORENO VALLEY CA
92555-2461
US

IV. Provider business mailing address

1242 UNIVERSITY AVE STE 6-570
RIVERSIDE CA
92507-8810
US

V. Phone/Fax

Practice location:
  • Phone: 760-612-7029
  • Fax:
Mailing address:
  • Phone: 760-612-7029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number31194
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: