Provider Demographics
NPI:1235664855
Name:OTERO, CRYSTAL MARIE (HIS)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:MARIE
Last Name:OTERO
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RIVER EDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07661-2011
Mailing Address - Country:US
Mailing Address - Phone:201-291-0550
Mailing Address - Fax:201-488-7900
Practice Address - Street 1:1021 MAIN ST
Practice Address - Street 2:
Practice Address - City:RIVER EDGE
Practice Address - State:NJ
Practice Address - Zip Code:07661-2011
Practice Address - Country:US
Practice Address - Phone:201-291-0550
Practice Address - Fax:201-488-7900
Is Sole Proprietor?:No
Enumeration Date:2017-04-21
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MG00133000237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist