1649528084 NPI number — CLINICAL SOCIAL WORKER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649528084 NPI number — CLINICAL SOCIAL WORKER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLINICAL SOCIAL WORKER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649528084
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 545
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLORIDA
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00650-0545
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-248-4873
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 CALLE CASIA
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN JUAN
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00921-3200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-248-4873
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/15/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ORTIZ GONZALEZ
Authorized Official First Name:
YANIRIS
Authorized Official Middle Name:
Authorized Official Title or Position:
SOCIAL WORKER
Authorized Official Telephone Number:
787-248-4873

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  9309 , 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)