Provider Demographics
NPI:1619327962
Name:OTTESON, MARGO
Entity Type:Individual
Prefix:MISS
First Name:MARGO
Middle Name:
Last Name:OTTESON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARGO
Other - Middle Name:ALAYNA
Other - Last Name:PEARCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2930 CLAUDE DOVE DR APT 11
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4871
Mailing Address - Country:US
Mailing Address - Phone:505-716-0377
Mailing Address - Fax:
Practice Address - Street 1:4700 N MESA ST
Practice Address - Street 2:SUITE F4
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-6171
Practice Address - Country:US
Practice Address - Phone:915-704-1094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-17
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX387572355S0801X
NMSLP6510235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant