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General NPI Number Information
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NPI Number | 1891813465
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Entity Type | Individual
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Provider Name | TINA SUE OTTO LPC, CADC
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Gender | Female
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Dates
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Enumeration Date | 03/26/2007
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Last Update Date | 05/05/2009
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Provider Practice Location Address
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Address Line | 421 W MAIN ST
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City | VANDALIA
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State | IL
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Zip | 62471-2214
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Country | US
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Telephone | 618-283-4229
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Fax |
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Provider Business Mailing Address
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Address Line | RR 1 BOX 300C
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City | RAMSEY
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State | IL
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Zip | 62080-9402
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Country | US
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Telephone | 618-423-9590
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 17890
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 178.006052
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License Number State | IL
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