=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295532596
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ILIANYS LASANTA ORTIZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2025
-----------------------------------------------------
Last Update Date | 02/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5 CALLE ALTURAS
-----------------------------------------------------
City | AIBONITO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00705-9802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-359-7640
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5 CALLE ALTURAS
-----------------------------------------------------
City | AIBONITO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00705-9802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-359-7640
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 8176
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------