Provider Demographics
NPI:1922310036
Name:CORTES LOPEZ, BRENDALIZ (MAESTRIA PSICOLOGIA)
Entity Type:Individual
Prefix:
First Name:BRENDALIZ
Middle Name:
Last Name:CORTES LOPEZ
Suffix:
Gender:F
Credentials:MAESTRIA PSICOLOGIA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CARRETERA 417 KM. 3.5 BO. GUANABANO
Mailing Address - Street 2:
Mailing Address - City:AGUADA
Mailing Address - State:PR
Mailing Address - Zip Code:00602
Mailing Address - Country:US
Mailing Address - Phone:787-244-2954
Mailing Address - Fax:
Practice Address - Street 1:CARRETERA 417 KM. 3.5 BO. GUANABANO
Practice Address - Street 2:
Practice Address - City:AGUADA
Practice Address - State:PR
Practice Address - Zip Code:00602
Practice Address - Country:US
Practice Address - Phone:787-244-2954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-06
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3521103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR120502Medicare PIN