Provider Demographics
NPI:1255791778
Name:SORTO AVILES, GLADYS YASMIN
Entity type:Individual
Prefix:
First Name:GLADYS
Middle Name:YASMIN
Last Name:SORTO AVILES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 BROOKWAY RD APT 526
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02131-1223
Mailing Address - Country:US
Mailing Address - Phone:617-412-7174
Mailing Address - Fax:
Practice Address - Street 1:3815 WASHINGTON ST STE 2
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02130-3760
Practice Address - Country:US
Practice Address - Phone:617-983-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-25
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA100016452235Medicaid