Provider Demographics
NPI:1679014500
Name:OTENNEY, JUAN (LPT)
Entity Type:Individual
Prefix:MR
First Name:JUAN
Middle Name:
Last Name:OTENNEY
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:JUAN
Other - Middle Name:R
Other - Last Name:OLVERA
Other - Suffix:JR
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1460 N LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91104-2300
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1460 N LAKE AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91104-2300
Practice Address - Country:US
Practice Address - Phone:626-294-1079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-10
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT29037167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician