Healthcare Provider Details

I. General information

NPI: 1730666587
Provider Name (Legal Business Name): DORISABEL HEREDIA OQUENDO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2018
Last Update Date: 07/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

472 AVE TITO CASTRO STE 100
PONCE PR
00716-4702
US

IV. Provider business mailing address

472 AVE TITO CASTRO STE 100
PONCE PR
00716-4702
US

V. Phone/Fax

Practice location:
  • Phone: 787-974-2316
  • Fax:
Mailing address:
  • Phone: 787-974-2316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number6065
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: