Basic Information
Provider Information
NPI: 1003150301
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BRAVO OTERO
FirstName: GLENDA
MiddleName: L.
NamePrefix:  
NameSuffix:  
Credential: MSW
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: BRAVO OTERO
OtherFirstName: GLENDA
OtherMiddleName: LIA
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential: MSW
OtherLastNameType: 1
Mailing Information
Address1: URB-SOL Y MAR 247
Address2:  
City: ISABELA
State: PR
PostalCode: 00662
CountryCode: US
TelephoneNumber: 7875605787
FaxNumber: 7878904989
Practice Location
Address1: URB-SOL Y MAR 247
Address2:  
City: ISABELA
State: PR
PostalCode: 00662
CountryCode: US
TelephoneNumber: 7878061687
FaxNumber: 7878061688
Other Information
ProviderEnumerationDate: 11/27/2012
LastUpdateDate: 11/27/2012
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
104100000X10466PRY Behavioral Health & Social Service ProvidersSocial Worker 
1041C0700X10466PRN Behavioral Health & Social Service ProvidersSocial WorkerClinical
1041S0200X10466PRN Behavioral Health & Social Service ProvidersSocial WorkerSchool

No ID Information.


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