Provider Demographics
NPI:1679142715
Name:OTERO, DESTINIE ANGEL (LSAA)
Entity Type:Individual
Prefix:
First Name:DESTINIE
Middle Name:ANGEL
Last Name:OTERO
Suffix:
Gender:F
Credentials:LSAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 ENCINO PL NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2612
Mailing Address - Country:US
Mailing Address - Phone:505-818-3058
Mailing Address - Fax:
Practice Address - Street 1:801 ENCINO PL NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2612
Practice Address - Country:US
Practice Address - Phone:505-272-2573
Practice Address - Fax:505-272-7751
Is Sole Proprietor?:No
Enumeration Date:2021-06-23
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCSA0216631101YA0400X
NM171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)