Provider Demographics
NPI:1538440615
Name:OTTENS, DEBRA ANN (PT)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:ANN
Last Name:OTTENS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1453 BANBURY LN
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:MS
Mailing Address - Zip Code:38632-7503
Mailing Address - Country:US
Mailing Address - Phone:901-497-8651
Mailing Address - Fax:
Practice Address - Street 1:83 AIRWAYS PL
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-5885
Practice Address - Country:US
Practice Address - Phone:662-349-8787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-02
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT4664225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist