MEDICARE: TRACI J OTTO MS

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	905	NE
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	LISAC-15036	AZ
3	101YM0800X	Mental Health Counselor	3011	NE
4	101YM0800X	Mental Health Counselor	436	NE
5	101YM0800X	Mental Health Counselor	LPC-15542	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	85632	OTHER	NE	BCBS PIN
2	250405	OTHER	NE	MIDLANDS CHOICE PIN
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073603437
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACI J OTTO MS

Provider Business Mailing Address
First Line	:	7474 SOUTH CAMINO DE OESTE
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85757
Country	:	US
Telephone Number	:	520-879-6077
Fax Number	:

Provider Business Practice Location Address
First Line	:	7474 SOUTH CAMINO DE OESTE
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85757
Country	:	US
Telephone Number	:	520-879-6077
Fax Number	:

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

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	12/16/2015

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Directions to “ TRACI J OTTO MS” Practice Location

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