Healthcare Provider Details

I. General information

NPI: 1770925646
Provider Name (Legal Business Name): KERRI HOTLEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2013
Last Update Date: 11/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 WILLIS AVE
DAYTONA BEACH FL
32114-2810
US

IV. Provider business mailing address

3865 S MACKINAC TRL
SAULT SAINTE MARIE MI
49783-9286
US

V. Phone/Fax

Practice location:
  • Phone: 800-538-4228
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801094849
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW14878
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: