Healthcare Provider Details

I. General information

NPI: 1306893946
Provider Name (Legal Business Name): DIANNA M. OTIENO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 01/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 W MAIN ST
HYANNIS MA
02601-3653
US

IV. Provider business mailing address

460 W MAIN ST
HYANNIS MA
02601-3653
US

V. Phone/Fax

Practice location:
  • Phone: 508-790-3360
  • Fax: 508-790-3378
Mailing address:
  • Phone: 508-790-3360
  • Fax: 508-790-3378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2026406
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: