Basic Information
| Provider Information | |||||||||
| NPI: | 1003150301 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRAVO OTERO | ||||||||
| FirstName: | GLENDA | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PSY.D | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRAVO OTERO | ||||||||
| OtherFirstName: | GLENDA | ||||||||
| OtherMiddleName: | LIA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | URB. SAN ANTONIO 345 | ||||||||
| Address2: | CALLE AGUACATE SAN ANTONIO PR | ||||||||
| City: | AGUADILLA | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7875438953 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | URB. SAN ANTONIO 345 | ||||||||
| Address2: | CALLE AGUACATE SAN ANTONIO PR | ||||||||
| City: | AGUADILLA | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7875438953 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2012 | ||||||||
| LastUpdateDate: | 09/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 10466 | PR | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 103TC0700X | 6619 | PR | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.