=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669128583
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAYRA IVETTE CORDERO GONZALEZ SOCIAL WORKER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2022
-----------------------------------------------------
Last Update Date | 03/01/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CARRETERA 107 EDIFICIO PLAZA DEL MAR
-----------------------------------------------------
City | AGUADILLA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-641-9133
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | URB JARDINES DE RINCON CALLE 2, CASA D8
-----------------------------------------------------
City | RINCON
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00677
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-605-5675
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------