{
"Npi": {
"NPI": "1952927600",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "N",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "DALE",
"FirstName": "LOURDES",
"MiddleName": "PORTALES",
"NamePrefix": "DR.",
"NameSuffix": null,
"Credential": "PHD",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "830-13 A1A NORTH",
"SecondLineMailingAddress": "#690",
"MailingAddressCityName": "PONTE VEDRA BEACH",
"MailingAddressStateName": "FL",
"MailingAddressPostalCode": "32082",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "860-305-2908",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "580 W 8TH ST FL TOWERII6",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "JACKSONVILLE",
"PracticeLocationAddressStateName": "FL",
"PracticeLocationAddressPostalCode": "32209-6533",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "860-305-2908",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "06/18/2020",
"LastUpdateDate": "06/18/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
"Gender": "Female",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "103T00000X",
"TaxonomyName": "Psychologist",
"LicenseNumber": "002436",
"LicenseNumberStateCode": "CT",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "103TC2200X",
"TaxonomyName": "Clinical Child & Adolescent Psychologist",
"LicenseNumber": "10538",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}