Healthcare Provider Details

I. General information

NPI: 1710685045
Provider Name (Legal Business Name): BRANDY CHRISTAL OTT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2023
Last Update Date: 11/11/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 S E ST
SAN BERNARDINO CA
92408-2773
US

IV. Provider business mailing address

2080 S E ST
SAN BERNARDINO CA
92408-2773
US

V. Phone/Fax

Practice location:
  • Phone: 909-433-9300
  • Fax:
Mailing address:
  • Phone: 94-339-3009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License NumberPT38056
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: