Provider Demographics
NPI:1609176866
Name:OTERO, ILEANSY
Entity Type:Individual
Prefix:
First Name:ILEANSY
Middle Name:
Last Name:OTERO
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 1:860 W 36TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-5164
Mailing Address - Country:US
Mailing Address - Phone:786-768-6499
Mailing Address - Fax:
Practice Address - Street 1:3412 W 84TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33018-4918
Practice Address - Country:US
Practice Address - Phone:305-827-7344
Practice Address - Fax:305-827-7382
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-21
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA13143235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist