Healthcare Provider Details

I. General information

NPI: 1144942343
Provider Name (Legal Business Name): REBECCA CAROLYN OTWELL-DOVE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: REBECCA CAROLYN OTWELL

II. Dates (important events)

Enumeration Date: 09/14/2022
Last Update Date: 09/14/2022
Certification Date: 09/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2002 BROOKSIDE DR STE 200
KINGSPORT TN
37660-4634
US

IV. Provider business mailing address

2002 BROOKSIDE DR STE 200
KINGSPORT TN
37660-4634
US

V. Phone/Fax

Practice location:
  • Phone: 423-530-7970
  • Fax:
Mailing address:
  • Phone: 423-530-7970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: