{
"Npi": {
"NPI": "1083836936",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "N",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "FUENTES FONSECA",
"FirstName": "LOURDES",
"MiddleName": null,
"NamePrefix": "DR.",
"NameSuffix": null,
"Credential": "PSY D",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": "ROLON",
"OtherFirstName": "LOURDES",
"OtherMiddleName": "FUENTES",
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": "PSY D",
"OtherLastNameTypeCode": "5",
"FirstLineMailingAddress": "PO BOX 9023252",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "SAN JUAN",
"MailingAddressStateName": "PR",
"MailingAddressPostalCode": "00902-3252",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "787-365-9572",
"MailingAddressFaxNumber": "787-725-5886",
"FirstLinePracticeLocationAddress": "301 CALLE RECINTO S",
"SecondLinePracticeLocationAddress": "CONDOMINIO GALLARDO OFIC 401-A",
"PracticeLocationAddressCityName": "SAN JUAN",
"PracticeLocationAddressStateName": "PR",
"PracticeLocationAddressPostalCode": "00901-1960",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "787-365-9572",
"PracticeLocationAddressFaxNumber": "787-725-5886",
"EnumerationDate": "05/02/2007",
"LastUpdateDate": "10/19/2016",
"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": "103T00000X",
"TaxonomyName": "Psychologist",
"LicenseNumber": "2108",
"LicenseNumberStateCode": "PR",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}