Provider Demographics
NPI:1205413135
Name:OTALVARO, MARIA
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:OTALVARO
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 1:8702 PINAFORE DR
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34653-6749
Mailing Address - Country:US
Mailing Address - Phone:727-967-2297
Mailing Address - Fax:
Practice Address - Street 1:1413 TECH BLVD STE 122
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33619-7822
Practice Address - Country:US
Practice Address - Phone:185-583-2672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-26
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-160774106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician