Healthcare Provider Details

I. General information

NPI: 1104341387
Provider Name (Legal Business Name): DR. MIRELISE CARTAGENA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2017
Last Update Date: 08/26/2021
Certification Date: 08/26/2021
Deactivation Date: 03/31/2021
Reactivation Date: 04/28/2021

III. Provider practice location address

3000 CONNECTICUT AVE NW STE 137A
WASHINGTON DC
20008-2549
US

IV. Provider business mailing address

3580 WILSHIRE BLVD STE 2000
LOS ANGELES CA
90010-2533
US

V. Phone/Fax

Practice location:
  • Phone: 202-299-0216
  • Fax:
Mailing address:
  • Phone: 213-381-1250
  • Fax: 213-383-4803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY1001706
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: