MEDICARE: AMY SUZANNE OTA LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	72064	TX

General Provider Information

NPI Number	:	1043751787
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY SUZANNE OTA LPC

Provider Business Mailing Address
First Line	:	8026 WHITWORTH LN
Second Line	:
City	:	ROUND ROCK
State	:	TX
Zip	:	78681-3416
Country	:	US
Telephone Number	:	512-944-2751
Fax Number	:

Provider Business Practice Location Address
First Line	:	595 ROUND ROCK WEST DR STE 104
Second Line	:
City	:	ROUND ROCK
State	:	TX
Zip	:	78681-5028
Country	:	US
Telephone Number	:	512-815-3723
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2017
Last Update Date	:	03/22/2019

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