Provider Demographics
NPI:1760947600
Name:OTANO, GLADYS MARIA
Entity Type:Individual
Prefix:
First Name:GLADYS
Middle Name:MARIA
Last Name:OTANO
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 1:8085 SW 206TH TER
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33189-2641
Mailing Address - Country:US
Mailing Address - Phone:786-399-2207
Mailing Address - Fax:
Practice Address - Street 1:8085 SW 206TH TER
Practice Address - Street 2:
Practice Address - City:CUTLER BAY
Practice Address - State:FL
Practice Address - Zip Code:33189-2641
Practice Address - Country:US
Practice Address - Phone:786-399-2207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-05
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-21-52040103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022566800Medicaid