MEDICARE: OTTMAN FAMILY THERAPY, PLLC

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1194524298
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OTTMAN FAMILY THERAPY, PLLC

Provider Business Mailing Address
First Line	:	480 ESSEN PL
Second Line	:
City	:	KERNERSVILLE
State	:	NC
Zip	:	27284-8332
Country	:	US
Telephone Number	:	202-823-2139
Fax Number	:

Provider Business Practice Location Address
First Line	:	3844 CLEMMONS RD
Second Line	:
City	:	CLEMMONS
State	:	NC
Zip	:	27012-7532
Country	:	US
Telephone Number	:	202-823-2139
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JACOB OTTMAN
Credential	:	LCMHC
Telephone Number	:	202-823-2139

Provider Enumeration Date	:	03/11/2025
Last Update Date	:	04/06/2026

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