Provider Demographics
NPI:1043783509
Name:DORESTE-MENDEZ, RAURA J (PHD)
Entity Type:Individual
Prefix:
First Name:RAURA
Middle Name:J
Last Name:DORESTE-MENDEZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 CALLE R MARTINEZ NADAL S APT 301
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00680-4978
Mailing Address - Country:US
Mailing Address - Phone:787-404-4516
Mailing Address - Fax:
Practice Address - Street 1:3512 QUENTIN RD STE 110
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-4245
Practice Address - Country:US
Practice Address - Phone:800-275-3243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP14493103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical