Provider Demographics
NPI:1366264087
Name:FERNANDEZ, OTIS DEAN
Entity type:Individual
Prefix:MR
First Name:OTIS
Middle Name:DEAN
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 CAROLINE AVE
Mailing Address - Street 2:
Mailing Address - City:JUNCTION CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66441-5210
Mailing Address - Country:US
Mailing Address - Phone:785-762-5250
Mailing Address - Fax:
Practice Address - Street 1:814 CAROLINE AVE
Practice Address - Street 2:
Practice Address - City:JUNCTION CITY
Practice Address - State:KS
Practice Address - Zip Code:66441-5210
Practice Address - Country:US
Practice Address - Phone:785-477-9241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-25
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
KSLPC-04889-T101YM0800X
KS04889101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health