Healthcare Provider Details

I. General information

NPI: 1497369557
Provider Name (Legal Business Name): NATHAN EDWARD OTT LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2020
Last Update Date: 09/04/2020
Certification Date: 09/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 CAMPUS DR
ABINGDON VA
24210-2589
US

IV. Provider business mailing address

610 CAMPUS DR
ABINGDON VA
24210-2589
US

V. Phone/Fax

Practice location:
  • Phone: 276-525-1550
  • Fax: 276-525-1609
Mailing address:
  • Phone: 276-525-1550
  • Fax: 276-525-1609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904012234
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: