Provider Demographics
NPI:1376199596
Name:OTERO, TAMMY LEA (LADC/MH)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:LEA
Last Name:OTERO
Suffix:
Gender:F
Credentials:LADC/MH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12501 W FOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:TONKAWA
Mailing Address - State:OK
Mailing Address - Zip Code:74653-4427
Mailing Address - Country:US
Mailing Address - Phone:505-263-1731
Mailing Address - Fax:
Practice Address - Street 1:12501 W FOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:TONKAWA
Practice Address - State:OK
Practice Address - Zip Code:74653-4427
Practice Address - Country:US
Practice Address - Phone:505-263-1731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-13
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 171M00000X
OK101YA0400X
OK1442101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator