Healthcare Provider Details

I. General information

NPI: 1811569759
Provider Name (Legal Business Name): KRISTEN OTTAKA LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2021
Last Update Date: 07/12/2021
Certification Date: 07/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3251 ROUTE 112 BLDG 9
MEDFORD NY
11763-1446
US

IV. Provider business mailing address

3251 ROUTE 112 BLDG 9
MEDFORD NY
11763-1446
US

V. Phone/Fax

Practice location:
  • Phone: 631-451-6007
  • Fax: 631-297-8121
Mailing address:
  • Phone: 631-451-6007
  • Fax: 631-297-8121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number011492
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: