MEDICARE: SANDRA EMERIC OTERO PSY.D.

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	103T00000X	Psychologist		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	007 1647960	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1700998028
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA EMERIC OTERO PSY.D.

Provider Business Mailing Address
First Line	:	PO BOX 478920
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-8920
Country	:	US
Telephone Number	:	773-786-2514
Fax Number	:

Provider Business Practice Location Address
First Line	:	2363 N CALIFORNIA AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-2939
Country	:	US
Telephone Number	:	773-786-2514
Fax Number	:

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

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	07/08/2007

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