Healthcare Provider Details

I. General information

NPI: 1437006780
Provider Name (Legal Business Name): SIMON DAVID OTERO III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2026
Last Update Date: 03/16/2026
Certification Date: 03/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4110 WOLCOTT AVE NE
ALBUQUERQUE NM
87109-4523
US

IV. Provider business mailing address

1922 AMOR DR NW
ALBUQUERQUE NM
87120-6021
US

V. Phone/Fax

Practice location:
  • Phone: 505-600-2279
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: