Provider Demographics
NPI:1750069878
Name:OTTLEY, KRYSTAL ANNE (LCSW)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:ANNE
Last Name:OTTLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 BROOK AVE APT 5V
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10455-1386
Mailing Address - Country:US
Mailing Address - Phone:917-679-6244
Mailing Address - Fax:
Practice Address - Street 1:704 BROOK AVE APT 5V
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-1386
Practice Address - Country:US
Practice Address - Phone:917-679-6244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0874371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical