Provider Demographics
NPI:1194504753
Name:OTANEZ, NADEJISA EDELWEISS
Entity type:Individual
Prefix:
First Name:NADEJISA
Middle Name:EDELWEISS
Last Name:OTANEZ
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 1:2481 SE CALIGULA AVE
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-6802
Mailing Address - Country:US
Mailing Address - Phone:772-486-6801
Mailing Address - Fax:
Practice Address - Street 1:4203 SW HIGH MEADOWS AVE
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-3726
Practice Address - Country:US
Practice Address - Phone:772-222-5560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician