Healthcare Provider Details

I. General information

NPI: 1215208814
Provider Name (Legal Business Name): JOSEPH HAROLD OTTERSTROM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2012
Last Update Date: 01/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 CRAFTON ST APT F-3
TAHLEQUAH OK
74464-7112
US

IV. Provider business mailing address

800 CRAFTON ST APT F-3
TAHLEQUAH OK
74464-7112
US

V. Phone/Fax

Practice location:
  • Phone: 918-402-4666
  • Fax:
Mailing address:
  • Phone: 918-402-4666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: