Provider Demographics
NPI:1467885442
Name:ADVANCE LOGISTIC PSYCHOLOGICAL EDUCATIONAL SERVICES, INC.
Entity Type:Organization
Organization Name:ADVANCE LOGISTIC PSYCHOLOGICAL EDUCATIONAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:ROSA
Authorized Official - Last Name:OTERO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-855-7400
Mailing Address - Street 1:22201 CARR.#2
Mailing Address - Street 2:
Mailing Address - City:VEGA BAJA
Mailing Address - State:PUERTO RICO
Mailing Address - Zip Code:00646
Mailing Address - Country:UM
Mailing Address - Phone:787-855-7400
Mailing Address - Fax:
Practice Address - Street 1:KM 4301 CARR. #2
Practice Address - Street 2:BO. ALGARROBO
Practice Address - City:VEGA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00646
Practice Address - Country:US
Practice Address - Phone:787-855-7400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-14
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4161103TA0400X, 103TC0700X
PR953235Z00000X
PR13642261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR4161OtherPUERTO RICO LICENSE PSYCHOLOGY- DRA. MARIA OTERO SURIA