Provider Demographics
NPI:1528843307
Name:OTT, TIA MICHELLE (SFA)
Entity type:Individual
Prefix:
First Name:TIA
Middle Name:MICHELLE
Last Name:OTT
Suffix:
Gender:F
Credentials:SFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12405 BUTLER DR NW
Mailing Address - Street 2:
Mailing Address - City:LAVALE
Mailing Address - State:MD
Mailing Address - Zip Code:21502-6027
Mailing Address - Country:US
Mailing Address - Phone:301-876-5440
Mailing Address - Fax:
Practice Address - Street 1:12502 WILLOWBROOK RD STE 500
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-6572
Practice Address - Country:US
Practice Address - Phone:301-722-8847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD209275246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant