Healthcare Provider Details

I. General information

NPI: 1477251288
Provider Name (Legal Business Name): MR. KENNETH ALEXIS CORREA I
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2023
Last Update Date: 02/21/2023
Certification Date: 02/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CDT CESAR ROSA FEBLES EDIFICIO ANEJO PISO2 SR 2, KM 50,
MANATI PR
00617
US

IV. Provider business mailing address

PO BOX 1570
BARCELONETA PR
00617-1570
US

V. Phone/Fax

Practice location:
  • Phone: 787-641-9133
  • Fax:
Mailing address:
  • Phone: 787-970-4634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number16354
License Number StatePR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier16354
Identifier TypeOTHER
Identifier StatePR
Identifier IssuerAPS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: