Provider Demographics
NPI:1043087323
Name:ATIENZA OTERO, EDELYS I
Entity type:Individual
Prefix:MRS
First Name:EDELYS
Middle Name:
Last Name:ATIENZA OTERO
Suffix:I
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 1:3225 INDEPENDENCE ST
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-4535
Mailing Address - Country:US
Mailing Address - Phone:863-853-0619
Mailing Address - Fax:
Practice Address - Street 1:3225 INDEPENDENCE ST
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-4535
Practice Address - Country:US
Practice Address - Phone:863-853-0619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-07
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23-313315106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician