Provider Demographics
NPI:1265996318
Name:OTHELLO, ELDA V (MS)
Entity type:Individual
Prefix:
First Name:ELDA
Middle Name:V
Last Name:OTHELLO
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:ELDA
Other - Middle Name:V
Other - Last Name:OTHELLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ELDA V OTHELLO, MS
Mailing Address - Street 1:3057 ACUSHNET AVE
Mailing Address - Street 2:
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02745-3636
Mailing Address - Country:US
Mailing Address - Phone:508-742-3921
Mailing Address - Fax:
Practice Address - Street 1:543 NORTH ST
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02740
Practice Address - Country:US
Practice Address - Phone:508-984-5566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110027934AMedicaid