Healthcare Provider Details

I. General information

NPI: 1194377127
Provider Name (Legal Business Name): LAURIE OTTENS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2019
Last Update Date: 07/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 PARK ST
WEED CA
96094-2332
US

IV. Provider business mailing address

317 W ALMA ST
MOUNT SHASTA CA
96067-2102
US

V. Phone/Fax

Practice location:
  • Phone: 530-938-4429
  • Fax:
Mailing address:
  • Phone: 530-859-0628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT14791
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: