Provider Demographics
NPI:1629952478
Name:BERDIEL, OTTO AGUSTIN (MS)
Entity type:Individual
Prefix:
First Name:OTTO
Middle Name:AGUSTIN
Last Name:BERDIEL
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 VIA ROMA
Mailing Address - Street 2:
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00976-6105
Mailing Address - Country:US
Mailing Address - Phone:787-509-6100
Mailing Address - Fax:787-292-0521
Practice Address - Street 1:1801 AVE PONCE DE LEON STE 411
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00909-1917
Practice Address - Country:US
Practice Address - Phone:787-509-6100
Practice Address - Fax:787-292-0521
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-04
Last Update Date:2025-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR831103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical