Provider Demographics
NPI:1700440682
Name:BEZARES, EDITH ROSE (OTL)
Entity Type:Individual
Prefix:MRS
First Name:EDITH
Middle Name:ROSE
Last Name:BEZARES
Suffix:
Gender:F
Credentials:OTL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:AVENIDA MARCELITO GOTAY
Mailing Address - Street 2:
Mailing Address - City:FAJARDO
Mailing Address - State:PR
Mailing Address - Zip Code:00738-1207
Mailing Address - Country:US
Mailing Address - Phone:787-801-5959
Mailing Address - Fax:787-801-2900
Practice Address - Street 1:CARR919 KM0.7 BO VALENCIANO ABAJO
Practice Address - Street 2:
Practice Address - City:JUNCOS
Practice Address - State:PR
Practice Address - Zip Code:00777
Practice Address - Country:US
Practice Address - Phone:787-691-8654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-26
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR665225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist