Provider Demographics
NPI:1861290348
Name:OTTO, ALEXIS ROSE
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:ROSE
Last Name:OTTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:679 W WILKINSON ST
Mailing Address - Street 2:
Mailing Address - City:VAIL
Mailing Address - State:AZ
Mailing Address - Zip Code:85641-0917
Mailing Address - Country:US
Mailing Address - Phone:702-672-2632
Mailing Address - Fax:
Practice Address - Street 1:8354 E NORTHFIELD BLVD UNIT 3700
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80238-3135
Practice Address - Country:US
Practice Address - Phone:702-672-2632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician