Healthcare Provider Details

I. General information

NPI: 1336363126
Provider Name (Legal Business Name): CATHY LYNN OTIS OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 09/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 LEBANON VALLEY CHURCH RD
CLEVELAND TN
37311-8477
US

IV. Provider business mailing address

500 LEBANON VALLEY CHURCH RD
CLEVELAND TN
37311-8477
US

V. Phone/Fax

Practice location:
  • Phone: 423-310-0555
  • Fax: 423-479-4421
Mailing address:
  • Phone: 423-310-0555
  • Fax: 423-479-4421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT2379
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT0000002379
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: