Provider Demographics
NPI:1316171093
Name:OTERO, ROLLY BETITA (PTA)
Entity type:Individual
Prefix:
First Name:ROLLY
Middle Name:BETITA
Last Name:OTERO
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:274 OGDEN AVE
Mailing Address - Street 2:BSMNT
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07307-1209
Mailing Address - Country:US
Mailing Address - Phone:201-658-1529
Mailing Address - Fax:
Practice Address - Street 1:729 PELHAM PKWY N
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-9506
Practice Address - Country:US
Practice Address - Phone:718-944-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-08
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP67888225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant