Healthcare Provider Details

I. General information

NPI: 1639220734
Provider Name (Legal Business Name): SHARON ELIZABETH OTIS ED.D, PH.D., L.M.H.C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5910 CORTEZ RD W STE 160
BRADENTON FL
34210-2706
US

IV. Provider business mailing address

3812 ROYAL PALM DR
BRADENTON FL
34210-1305
US

V. Phone/Fax

Practice location:
  • Phone: 941-792-4988
  • Fax:
Mailing address:
  • Phone: 941-792-4988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH-1682
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: