Healthcare Provider Details

I. General information

NPI: 1063189769
Provider Name (Legal Business Name): KELLI ANNE OTSUKA ED.S., NCSP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2021
Last Update Date: 08/30/2021
Certification Date: 08/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2658 N SHEFFORD CT
WICHITA KS
67205-2063
US

IV. Provider business mailing address

2658 N SHEFFORD CT
WICHITA KS
67205-2063
US

V. Phone/Fax

Practice location:
  • Phone: 316-691-7851
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number4594295371
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: