Active NPI
Walter (Rusty) Wallace Otto, PHD
- Psychologist
- Sacramento, CA
National Provider Identifier
1649682469
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Psychologist
- License
- PSY12396
- Practice address
- 1970 University Park Drive
Sacramento, CA 95825 - Phone
- (916) 804-5087
- NPI assigned
- May 28, 2014
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Psychologist | 103T00000X | PSY12396 | CA | Primary |
Addresses
Primary practice location
1970 University Park Drive
Sacramento, CA 95825
Mailing address
1970 University Park Drive
Sacramento, CA 95825
Phone (916) 804-5087
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PSY12396 | CA | MD | Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1401235200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1401235200000",
"number": "1649682469",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1970 UNIVERSITY PARK DRIVE",
"city": "SACRAMENTO",
"state": "CA",
"postal_code": "95825",
"telephone_number": "916-804-5087"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1970 UNIVERSITY PARK DRIVE",
"city": "SACRAMENTO",
"state": "CA",
"postal_code": "95825",
"telephone_number": "916-804-5087"
}
],
"practiceLocations": [],
"basic": {
"last_name": "OTTO",
"first_name": "WALTER (RUSTY)",
"middle_name": "WALLACE",
"credential": "PHD",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2014-05-28",
"last_updated": "2014-05-28",
"status": "A"
},
"taxonomies": [
{
"code": "103T00000X",
"taxonomy_group": "",
"desc": "Psychologist",
"state": "CA",
"license": "PSY12396",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Sacramento, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 28, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.