Healthcare Provider Details

I. General information

NPI: 1730098161
Provider Name (Legal Business Name): MARISSA ANN OTTEN LGSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARISSA ANN GILLHAM

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 N ROGERS LN STE 121
RALEIGH NC
27610-6083
US

IV. Provider business mailing address

8726 CHURCH CIR
CLEAR LAKE MN
55319-4520
US

V. Phone/Fax

Practice location:
  • Phone: 910-216-9530
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number36136
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP024523
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: