Provider Demographics
NPI:1417785064
Name:OTERO VICTORERO, ALEXANDRA DE LA CARIDAD
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:DE LA CARIDAD
Last Name:OTERO VICTORERO
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 1:17710 NW 73RD AVE APT 205
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-6211
Mailing Address - Country:US
Mailing Address - Phone:786-973-6788
Mailing Address - Fax:
Practice Address - Street 1:17710 NW 73RD AVE APT 205
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-6211
Practice Address - Country:US
Practice Address - Phone:786-973-6788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-24
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-364111106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty