Provider Demographics
NPI:1144630484
Name:OTWELL, WILIAM BRADFORD
Entity type:Individual
Prefix:
First Name:WILIAM
Middle Name:BRADFORD
Last Name:OTWELL
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 1:110 WATTS ST
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72601-6540
Mailing Address - Country:US
Mailing Address - Phone:314-753-7271
Mailing Address - Fax:
Practice Address - Street 1:110 WATTS ST
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-6540
Practice Address - Country:US
Practice Address - Phone:314-753-7271
Practice Address - Fax:870-741-5098
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-07
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator