Healthcare Provider Details

I. General information

NPI: 1093629784
Provider Name (Legal Business Name): BETH OTT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9433 MAPLE RIDGE DR
NEWPORT MI
48166-9294
US

IV. Provider business mailing address

9433 MAPLE RIDGE DR
NEWPORT MI
48166-9294
US

V. Phone/Fax

Practice location:
  • Phone: 313-525-0668
  • Fax:
Mailing address:
  • Phone: 313-525-0668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801119339
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: