MEDICARE: IXIA REYES TORRES M.S.W

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	9260	PR
2	1041C0700X	Clinical Social Worker	9260	PR

General Provider Information

NPI Number	:	1235599648
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IXIA REYES TORRES M.S.W

Provider Business Mailing Address
First Line	:	COND BORINQUEN PARK # I
Second Line	:	1484 AVE FD ROOSVELT
City	:	SAN JUAN
State	:	PR
Zip	:	00911-1148
Country	:	US
Telephone Number	:	787-949-1066
Fax Number	:

Provider Business Practice Location Address
First Line	:	1484 AVE FD ROOSVELT
Second Line	:
City	:	SAN JUAN
State	:	PR
Zip	:	00920-2724
Country	:	US
Telephone Number	:	787-949-1066
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/26/2016
Last Update Date	:	03/23/2016

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