Provider Demographics
NPI:1982345476
Name:OTERO, PRISCILA ALEXIS
Entity Type:Individual
Prefix:
First Name:PRISCILA
Middle Name:ALEXIS
Last Name:OTERO
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 1:673 PEAR DR
Mailing Address - Street 2:
Mailing Address - City:FRUITA
Mailing Address - State:CO
Mailing Address - Zip Code:81521-2284
Mailing Address - Country:US
Mailing Address - Phone:970-640-8325
Mailing Address - Fax:
Practice Address - Street 1:2708 PATTERSON RD
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-4031
Practice Address - Country:US
Practice Address - Phone:970-243-9539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-06
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACC.0998690101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)