Healthcare Provider Details

I. General information

NPI: 1396560876
Provider Name (Legal Business Name): LAUREL MARGARET OTIS PSYD, LP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2024
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 FREEMAN DR
SAINT PETER MN
56082-3504
US

IV. Provider business mailing address

100 FREEMAN DR
SAINT PETER MN
56082-3504
US

V. Phone/Fax

Practice location:
  • Phone: 507-985-2339
  • Fax:
Mailing address:
  • Phone: 507-985-2339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP6122
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: