Provider Demographics
NPI:1457997959
Name:OTSUKA, STACEY
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:OTSUKA
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 1:6318 DONA LINDA PL NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-3729
Mailing Address - Country:US
Mailing Address - Phone:505-453-4083
Mailing Address - Fax:
Practice Address - Street 1:8001 MOUNTAIN ROAD PL NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-7808
Practice Address - Country:US
Practice Address - Phone:505-453-4083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-20
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCMH0207931101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health