Provider Demographics
NPI:1619495439
Name:TAVAREZ SOTO, MIREYA LISSETTE (MSW)
Entity Type:Individual
Prefix:
First Name:MIREYA
Middle Name:LISSETTE
Last Name:TAVAREZ SOTO
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PASEOS REALES 745 AVE. EMPERADOR
Mailing Address - Street 2:
Mailing Address - City:ARECIBO
Mailing Address - State:PR
Mailing Address - Zip Code:00612
Mailing Address - Country:US
Mailing Address - Phone:787-370-1883
Mailing Address - Fax:
Practice Address - Street 1:PR 863 KM 1
Practice Address - Street 2:BO. CANDELARIA SECTOR PAJAROS
Practice Address - City:TOA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00949
Practice Address - Country:US
Practice Address - Phone:787-862-3000
Practice Address - Fax:787-862-2731
Is Sole Proprietor?:No
Enumeration Date:2017-08-31
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6131104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker