=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104176528
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DALLY RIOS ORTEGA, PSY.D., LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2012
-----------------------------------------------------
Last Update Date | 09/12/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10294 CAROLINE PARK DR
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32832-5865
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-519-2546
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10294 CAROLINE PARK DR
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32832-5865
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-519-2546
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST
-----------------------------------------------------
Name | DR. DALLY I RIOS ORTEGA
-----------------------------------------------------
Credential | PSY. D
-----------------------------------------------------
Telephone | 804-519-2546
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PY 8383
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------