Healthcare Provider Details

I. General information

NPI: 1003512617
Provider Name (Legal Business Name): MAYRA AGOSTO ORTEGA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2023
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CENTRO INTERNACIONAL DE MERCADEO TORRE 1 SUITE 401
GUAYNABO PR
00965
US

IV. Provider business mailing address

421 CALLE RIVADAVIA VALENCIA
SAN JUAN PR
00923
US

V. Phone/Fax

Practice location:
  • Phone: 787-340-6455
  • Fax:
Mailing address:
  • Phone: 787-340-6455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number15001
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: