Basic Information
| Provider Information | |||||||||
| NPI: | 1831506476 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORDERO | ||||||||
| FirstName: | JUAN | ||||||||
| MiddleName: | CARLOS | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S., M.A., PSY.D | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CORDERO | ||||||||
| OtherFirstName: | JUAN | ||||||||
| OtherMiddleName: | CARLOS | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.A. , M.S, PSY.D | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2 WATERSIDE XING STE 401 | ||||||||
| Address2: | |||||||||
| City: | WINDSOR | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060951587 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606973351 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 433 VALLEY ST | ||||||||
| Address2: | |||||||||
| City: | WILLIMANTIC | ||||||||
| State: | CT | ||||||||
| PostalCode: | 062261901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604567200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2014 | ||||||||
| LastUpdateDate: | 10/10/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YM0800X | 002740 | PR | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103TC0700X | 002740 | PR | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.