Provider Demographics
NPI:1811569759
Name:OTTAKA, KRISTEN (LMHC)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:OTTAKA
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3251 ROUTE 112 BLDG 9
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-1446
Mailing Address - Country:US
Mailing Address - Phone:631-451-6007
Mailing Address - Fax:631-297-8121
Practice Address - Street 1:3251 ROUTE 112 BLDG 9
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-1446
Practice Address - Country:US
Practice Address - Phone:631-451-6007
Practice Address - Fax:631-297-8121
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011492101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health