Provider Demographics
NPI:1164660759
Name:OTERO, EDNA I
Entity Type:Individual
Prefix:
First Name:EDNA
Middle Name:I
Last Name:OTERO
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:PO BOX 1195
Mailing Address - Street 2:
Mailing Address - City:SANTA ISABEL
Mailing Address - State:PR
Mailing Address - Zip Code:00757-1195
Mailing Address - Country:US
Mailing Address - Phone:787-648-5514
Mailing Address - Fax:787-845-1188
Practice Address - Street 1:AVE. LUIS MUNOZ RIVERA 91
Practice Address - Street 2:
Practice Address - City:SANTA ISABEL
Practice Address - State:PR
Practice Address - Zip Code:00757
Practice Address - Country:US
Practice Address - Phone:787-845-1188
Practice Address - Fax:787-845-1188
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-04
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR17041104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker