MEDICARE: GERALD OTT

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	0704016631	VA
2	101YM0800X	Mental Health Counselor	0704016631	VA

General Provider Information

NPI Number	:	1982475174
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GERALD OTT

Provider Business Mailing Address
First Line	:	PO BOX 748465
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-8465
Country	:	US
Telephone Number	:	855-284-7483
Fax Number	:	617-807-0958

Provider Business Practice Location Address
First Line	:	16035 CONTINENTAL BLVD
Second Line	:
City	:	SOUTH CHESTERFIELD
State	:	VA
Zip	:	23834-5900
Country	:	US
Telephone Number	:	804-336-3068
Fax Number	:

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

Provider Enumeration Date	:	01/16/2024
Last Update Date	:	09/03/2024

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Directions to “ GERALD OTT ” Practice Location

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