Healthcare Provider Details

I. General information

NPI: 1467942490
Provider Name (Legal Business Name): DONNA BETH OTIS PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2018
Last Update Date: 05/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

648 BEACON ST
BOSTON MA
02215-2012
US

IV. Provider business mailing address

64 HIGH ROCK TER
CHESTNUT HILL MA
02467-2654
US

V. Phone/Fax

Practice location:
  • Phone: 617-353-9610
  • Fax:
Mailing address:
  • Phone: 617-233-2625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number8518
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: