Provider Demographics
NPI:1083503734
Name:GARRARD, OTELLO MILLER
Entity type:Individual
Prefix:
First Name:OTELLO
Middle Name:MILLER
Last Name:GARRARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 S HOLMAN WAY APT 3B
Mailing Address - Street 2:
Mailing Address - City:GOLDEN
Mailing Address - State:CO
Mailing Address - Zip Code:80401-5167
Mailing Address - Country:US
Mailing Address - Phone:512-589-0905
Mailing Address - Fax:
Practice Address - Street 1:1035 EL RANCHO RD
Practice Address - Street 2:
Practice Address - City:EVERGREEN
Practice Address - State:CO
Practice Address - Zip Code:80439-8238
Practice Address - Country:US
Practice Address - Phone:720-295-3790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-30
Last Update Date:2025-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24-342990106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician