Provider Demographics
NPI:1326605908
Name:OTERO DESANTIAGO, LUIS ANTONIO III
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:ANTONIO
Last Name:OTERO DESANTIAGO
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14411 COMMERCE WAY STE 350
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33016-1600
Mailing Address - Country:US
Mailing Address - Phone:305-530-8119
Mailing Address - Fax:
Practice Address - Street 1:14411 COMMERCE WAY STE 350
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33016-1600
Practice Address - Country:US
Practice Address - Phone:305-530-8119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-20
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH16655101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health