Provider Demographics
NPI:1346953643
Name:OTERO, ENRIQUE (MED, LPC)
Entity Type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:
Last Name:OTERO
Suffix:
Gender:M
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8804 TIGRIS TRL
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76118-7460
Mailing Address - Country:US
Mailing Address - Phone:817-793-7463
Mailing Address - Fax:
Practice Address - Street 1:8804 TIGRIS TRL
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76118-7460
Practice Address - Country:US
Practice Address - Phone:817-793-7463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-02
Last Update Date:2023-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14131101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional