=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700165560
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARLOS AVILES-REYES PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2011
-----------------------------------------------------
Last Update Date | 08/11/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | URB. PAISAJE DEL RIO CALLE C-6
-----------------------------------------------------
City | LUQUILLO
-----------------------------------------------------
State | PUERTO RICO
-----------------------------------------------------
Zip | 00773
-----------------------------------------------------
Country | UM
-----------------------------------------------------
Telephone | 787-949-7369
-----------------------------------------------------
Fax | 787-355-7802
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | BO. LOMAS K.1.9 P.O.BOX 2051
-----------------------------------------------------
City | CANOVANAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00729-2051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-949-7369
-----------------------------------------------------
Fax | 787-355-7802
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 1434
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------