Provider Demographics
NPI:1184872855
Name:OTTERBACHER, JOHN ROBERT (PHD-CLINICAL PSYCH)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROBERT
Last Name:OTTERBACHER
Suffix:
Gender:M
Credentials:PHD-CLINICAL PSYCH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 MONROE CENTER
Mailing Address - Street 2:SUITE 730
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503
Mailing Address - Country:US
Mailing Address - Phone:616-634-2467
Mailing Address - Fax:616-454-2855
Practice Address - Street 1:146 MONROE CENTER
Practice Address - Street 2:SUITE 730
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503
Practice Address - Country:US
Practice Address - Phone:616-634-2467
Practice Address - Fax:616-454-2855
Is Sole Proprietor?:No
Enumeration Date:2008-09-05
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301000990103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical