MEDICARE: AMANDA I OTT DT

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	222Q00000X	Developmental Therapist

General Provider Information

NPI Number	:	1063169613
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA I OTT DT

Provider Business Mailing Address
First Line	:	1233 W ADAMS ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60607-2801
Country	:	US
Telephone Number	:	312-243-8487
Fax Number	:

Provider Business Practice Location Address
First Line	:	3021 N MANGO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-5217
Country	:	US
Telephone Number	:	773-992-0686
Fax Number	:

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

Provider Enumeration Date	:	03/03/2022
Last Update Date	:	06/04/2024

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