Provider Demographics
NPI:1891441135
Name:OTSUKA, KRISTYN THERESE (LCSW)
Entity Type:Individual
Prefix:
First Name:KRISTYN
Middle Name:THERESE
Last Name:OTSUKA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7555 PRAIRIE RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-1828
Mailing Address - Country:US
Mailing Address - Phone:505-301-1571
Mailing Address - Fax:
Practice Address - Street 1:1501 SAN PEDRO DR NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-6731
Practice Address - Country:US
Practice Address - Phone:505-301-1571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-24
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-121111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical