=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861229684
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHANY M ORTIZ MIRANDA SR. PSYD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2024
-----------------------------------------------------
Last Update Date | 03/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 735 AVE PONCE DE LEON TORRE DE AUXILIO MUTUO STE 410
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00917-5025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-704-0705
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | CONCORDIA GRADENS I 12-C CALLE LIVORNA
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-702-2434
-----------------------------------------------------
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 | 15228
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 8225
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------