Healthcare Provider Details

I. General information

NPI: 1831471168
Provider Name (Legal Business Name): NICOLE J OTIS LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2011
Last Update Date: 08/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 8TH AVE N
SAINT CLOUD MN
56303-3420
US

IV. Provider business mailing address

139 22ND AVE N
SAINT CLOUD MN
56303-4331
US

V. Phone/Fax

Practice location:
  • Phone: 320-266-1693
  • Fax: 320-251-0217
Mailing address:
  • Phone: 320-266-1693
  • Fax: 320-251-0217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number2129
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: