Healthcare Provider Details

I. General information

NPI: 1427313196
Provider Name (Legal Business Name): CAROLINA BERTHA PRIETO M.S, E.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2012
Last Update Date: 07/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4024 AMBOY RD
STATEN ISLAND NY
10308-2409
US

IV. Provider business mailing address

85 ELMWOOD PARK DR APT 47
STATEN ISLAND NY
10314-7868
US

V. Phone/Fax

Practice location:
  • Phone: 718-984-9022
  • Fax:
Mailing address:
  • Phone: 718-530-2362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number194683081
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number210592081
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: