{
"Npi": {
"NPI": "1003150301",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "Y",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "BRAVO OTERO",
"FirstName": "GLENDA",
"MiddleName": "L.",
"NamePrefix": null,
"NameSuffix": null,
"Credential": "PSY.D",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": "BRAVO OTERO",
"OtherFirstName": "GLENDA",
"OtherMiddleName": "LIA",
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": "MSW",
"OtherLastNameTypeCode": "1",
"FirstLineMailingAddress": "URB. SAN ANTONIO 345",
"SecondLineMailingAddress": "CALLE AGUACATE SAN ANTONIO PR",
"MailingAddressCityName": "AGUADILLA",
"MailingAddressStateName": "PR",
"MailingAddressPostalCode": "00690",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "787-543-8953",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "URB. SAN ANTONIO 345",
"SecondLinePracticeLocationAddress": "CALLE AGUACATE SAN ANTONIO PR",
"PracticeLocationAddressCityName": "AGUADILLA",
"PracticeLocationAddressStateName": "PR",
"PracticeLocationAddressPostalCode": "00690",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "787-543-8953",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "11/27/2012",
"LastUpdateDate": "09/22/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
"Gender": "Female",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "1041C0700X",
"TaxonomyName": "Clinical Social Worker",
"LicenseNumber": "10466",
"LicenseNumberStateCode": "PR",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "103TC0700X",
"TaxonomyName": "Clinical Psychologist",
"LicenseNumber": "6619",
"LicenseNumberStateCode": "PR",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}