Provider Demographics
NPI:1427143965
Name:OTTENHEIMER, HOWARD M (PHD)
Entity type:Individual
Prefix:
First Name:HOWARD
Middle Name:M
Last Name:OTTENHEIMER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6528 BARRANCA DR
Mailing Address - Street 2:
Mailing Address - City:COCHITI LAKE
Mailing Address - State:NM
Mailing Address - Zip Code:87083-6009
Mailing Address - Country:US
Mailing Address - Phone:505-989-3639
Mailing Address - Fax:
Practice Address - Street 1:411 SAINT MICHAELS DR
Practice Address - Street 2:SUITE, 8
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7655
Practice Address - Country:US
Practice Address - Phone:505-989-3639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2008-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM672103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical