=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952927600
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LOURDES PORTALES DALE PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2020
-----------------------------------------------------
Last Update Date | 06/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 580 W 8TH ST FL TOWERII6
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32209-6533
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-305-2908
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 830-13 A1A NORTH #690
-----------------------------------------------------
City | PONTE VEDRA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32082
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-305-2908
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 002436
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | 10538
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------