MEDICARE: MR. IVAN AUDBERTO BAUZA HENRIQUEZ MA

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	103TC1900X	Counseling Psychologist	1886	PR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3087	OTHER	PR	APS
2	580437	OTHER	PR	FHCHS OF PR

General Provider Information

NPI Number	:	1770774143
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. IVAN AUDBERTO BAUZA HENRIQUEZ MA

Provider Business Mailing Address
First Line	:	PO BOX 10817
Second Line	:
City	:	SAN JUAN
State	:	PR
Zip	:	00922
Country	:	US
Telephone Number	:	787-661-0174
Fax Number	:	787-858-0218

Provider Business Practice Location Address
First Line	:	1056 AVE MUNOZ RIVERA
Second Line	:	SUITE 608 FIRST FEDERAL BUILDING
City	:	RIO PIEDRAS
State	:	PR
Zip	:	00927-5015
Country	:	US
Telephone Number	:	787-661-0174
Fax Number	:	787-858-0218

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

Provider Enumeration Date	:	08/09/2007
Last Update Date	:	08/20/2008

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Directions to “ MR. IVAN AUDBERTO BAUZA HENRIQUEZ MA” Practice Location

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