Provider Demographics
NPI:1003150301
Name:BRAVO OTERO, GLENDA L (PSYD)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:L
Last Name:BRAVO OTERO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:GLENDA
Other - Middle Name:LIA
Other - Last Name:BRAVO OTERO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:URB. SAN ANTONIO 345
Mailing Address - Street 2:CALLE AGUACATE SAN ANTONIO PR
Mailing Address - City:AGUADILLA
Mailing Address - State:PR
Mailing Address - Zip Code:00690
Mailing Address - Country:US
Mailing Address - Phone:787-543-8953
Mailing Address - Fax:
Practice Address - Street 1:URB. SAN ANTONIO 345
Practice Address - Street 2:CALLE AGUACATE SAN ANTONIO PR
Practice Address - City:AGUADILLA
Practice Address - State:PR
Practice Address - Zip Code:00690
Practice Address - Country:US
Practice Address - Phone:787-543-8953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-27
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR104661041C0700X, 1041S0200X
PR6619103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool