Healthcare Provider Details

I. General information

NPI: 1124879655
Provider Name (Legal Business Name): HANNAH E OTTOSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2024
Last Update Date: 04/01/2024
Certification Date: 04/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 LUBBUCK CT
MOSCOW MILLS MO
63362-0411
US

IV. Provider business mailing address

600 LUBBUCK CT
MOSCOW MILLS MO
63362-0411
US

V. Phone/Fax

Practice location:
  • Phone: 636-344-0898
  • Fax:
Mailing address:
  • Phone: 636-297-0054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2020014984
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: