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
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
103TC0700X6619PRY193400000X SINGLE SPECIALTY GROUPBehavioral Health & Social Service ProvidersPsychologistClinical
1041C0700X10466PRN Behavioral Health & Social Service ProvidersSocial WorkerClinical

No ID Information.


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