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General NPI Number Information
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NPI Number | 1639621857
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Entity Type | Organization
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Legal Business Name | OTTENBREIT PSYCHOTHERAPY ASSOCIATES, LLC
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Dates
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Enumeration Date | 11/04/2016
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Last Update Date | 12/05/2016
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Provider Practice Location Address
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Address Line | 835 MASON ST B-200
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City | DEARBORN
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State | MI
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Zip | 48124-2231
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Country | US
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Telephone | 313-575-6297
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Fax | 313-406-4617
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Provider Business Mailing Address
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Address Line | 835 MASON ST B-200
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City | DEARBORN
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State | MI
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Zip | 48124-2231
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Country | US
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Telephone | 313-575-6297
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Fax | 313-406-4617
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Authorized Official
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Title or Position | CLINICAL SOCIAL WORKER
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Name | MR. BRUCE D. OTTENBREIT
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Credential | LMSW, ASCW
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Telephone | 313-575-6297
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | MSW-6801007603
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License Number State | MI
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