=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790067924
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARMEN TERESITA OTERO CORDERO T.S
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2011
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | COND. PARQUE DE LA VISTA 2 1294 CALLE JUAN BAIZ APT 2133
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00924-1203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-426-6161
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | COND. PARQUE DE LA VISTA 2 1294 CALLE JUAN BAIZ APT 2133
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00924-1203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-426-6161
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 10436
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 7039
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------