Provider Demographics
NPI:1316303118
Name:ORTIZ RODRIGUEZ, GLORYNELL (PSYD)
Entity type:Individual
Prefix:DR
First Name:GLORYNELL
Middle Name:
Last Name:ORTIZ RODRIGUEZ
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1902
Mailing Address - Street 2:
Mailing Address - City:CIDRA
Mailing Address - State:PR
Mailing Address - Zip Code:00739-1902
Mailing Address - Country:US
Mailing Address - Phone:787-595-6593
Mailing Address - Fax:
Practice Address - Street 1:34 CARR 172 CALLE DOCTOR IGUINA
Practice Address - Street 2:
Practice Address - City:CIDRA
Practice Address - State:PR
Practice Address - Zip Code:00739
Practice Address - Country:US
Practice Address - Phone:787-595-6593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-08
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4318103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR4318OtherPSYCHOLOGY