Provider Demographics
NPI:1770774143
Name:BAUZA HENRIQUEZ, IVAN AUDBERTO (MA)
Entity type:Individual
Prefix:MR
First Name:IVAN
Middle Name:AUDBERTO
Last Name:BAUZA HENRIQUEZ
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
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Mailing Address - Street 1:PO BOX 10817
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00922
Mailing Address - Country:US
Mailing Address - Phone:787-661-0174
Mailing Address - Fax:787-858-0218
Practice Address - Street 1:1056 AVE MUNOZ RIVERA
Practice Address - Street 2:SUITE 608 FIRST FEDERAL BUILDING
Practice Address - City:RIO PIEDRAS
Practice Address - State:PR
Practice Address - Zip Code:00927-5015
Practice Address - Country:US
Practice Address - Phone:787-661-0174
Practice Address - Fax:787-858-0218
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-09
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PR1886103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR3087OtherAPS
PR580437OtherFHCHS OF PR
PR580437OtherFHCHS OF PR