1083836936 NPI number — DR. LOURDES FUENTES FONSECA PSY D

Table of content: DR. LOURDES FUENTES FONSECA PSY D (NPI 1083836936)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083836936 NPI number — DR. LOURDES FUENTES FONSECA PSY D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FUENTES FONSECA
Provider First Name:
LOURDES
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSY D
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROLON
Provider Other First Name:
LOURDES
Provider Other Middle Name:
FUENTES
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PSY D
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1083836936
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/19/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9023252
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN JUAN
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00902-3252
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-365-9572
Provider Business Mailing Address Fax Number:
787-725-5886

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 CALLE RECINTO S
Provider Second Line Business Practice Location Address:
CONDOMINIO GALLARDO OFIC 401-A
Provider Business Practice Location Address City Name:
SAN JUAN
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00901-1960
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-365-9572
Provider Business Practice Location Address Fax Number:
787-725-5886
Provider Enumeration Date:
05/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  2108 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2466 . This is a "APS HUMANA" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 500950 . This is a "FHC" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: P559 . This is a "FIRST MEDICAL" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 56610 . This is a "SSS" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com