Provider Demographics
NPI:1982978615
Name:OTOTIVO, BENJAMIN ZACHARY (BA)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:ZACHARY
Last Name:OTOTIVO
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2681 JEFFERSON ST
Mailing Address - Street 2:APT 622
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-5667
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:103 GIBBS DR
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072
Practice Address - Country:US
Practice Address - Phone:405-573-3955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-27
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor