Healthcare Provider Details

I. General information

NPI: 1417941329
Provider Name (Legal Business Name): LARRY O OTWELL AUD CCCA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 04/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2518 S HIGHWAY 77 STE A
LYNN HAVEN FL
32444-4730
US

IV. Provider business mailing address

2518 S HIGHWAY 77 STE A
LYNN HAVEN FL
32444-4730
US

V. Phone/Fax

Practice location:
  • Phone: 850-769-2705
  • Fax: 850-769-1097
Mailing address:
  • Phone: 850-769-2705
  • Fax: 850-769-1097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAY370
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: