Healthcare Provider Details

I. General information

NPI: 1386536290
Provider Name (Legal Business Name): MICHAELA E OTTINO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2025
Last Update Date: 07/16/2025
Certification Date: 07/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2921 LACKLAND RD
FORT WORTH TX
76116-4173
US

IV. Provider business mailing address

2109 SAINT JAMES PL
KELLER TX
76248-8352
US

V. Phone/Fax

Practice location:
  • Phone: 210-216-6367
  • Fax:
Mailing address:
  • Phone: 704-975-9470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2184935
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: