MEDICARE: MRS. EDELYS ATIENZA OTERO I

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	23-313315	FL

General Provider Information

NPI Number	:	1043087323
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. EDELYS ATIENZA OTERO I

Provider Business Mailing Address
First Line	:	3225 INDEPENDENCE ST
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33803-4535
Country	:	US
Telephone Number	:	863-853-0619
Fax Number	:

Provider Business Practice Location Address
First Line	:	3225 INDEPENDENCE ST
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33803-4535
Country	:	US
Telephone Number	:	863-853-0619
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/07/2023
Last Update Date	:	05/27/2026

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