Provider Demographics
NPI:1205569498
Name:OTT, SOMMER ROSE
Entity type:Individual
Prefix:MRS
First Name:SOMMER
Middle Name:ROSE
Last Name:OTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SOMMER
Other - Middle Name:ROSE
Other - Last Name:VADEBONCOEUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2051 HANCOCK ST
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44052-3229
Mailing Address - Country:US
Mailing Address - Phone:440-864-2179
Mailing Address - Fax:
Practice Address - Street 1:6145 PARK SQUARE DR
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-4146
Practice Address - Country:US
Practice Address - Phone:440-370-3007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-05
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2103554-TRNE101YM0800X
OHC.2305037101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health