Provider Demographics
NPI:1649528084
Name:CLINICAL SOCIAL WORKER
Entity type:Organization
Organization Name:CLINICAL SOCIAL WORKER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:YANIRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:ORTIZ GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LICENSE # 9309
Authorized Official - Phone:787-248-4873
Mailing Address - Street 1:PO BOX 545
Mailing Address - Street 2:
Mailing Address - City:FLORIDA
Mailing Address - State:PR
Mailing Address - Zip Code:00650-0545
Mailing Address - Country:US
Mailing Address - Phone:787-248-4873
Mailing Address - Fax:
Practice Address - Street 1:10 CALLE CASIA
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00921-3200
Practice Address - Country:US
Practice Address - Phone:787-248-4873
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR9309251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health