MEDICARE: DR. LUIS COLLAZO PHD

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	103TC0700X	Clinical Psychologist	2953	PR

General Provider Information

NPI Number	:	1104081181
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LUIS COLLAZO PHD

Provider Business Mailing Address
First Line	:	L4 CALLE BOLIVIA
Second Line	:	OASIS GARDENS
City	:	GUAYNABO
State	:	PR
Zip	:	00969-3413
Country	:	US
Telephone Number	:	787-525-2110
Fax Number	:

Provider Business Practice Location Address
First Line	:	L4 CALLE BOLIVIA
Second Line	:	OASIS GARDENS
City	:	GUAYNABO
State	:	PR
Zip	:	00969-3413
Country	:	US
Telephone Number	:	787-525-2110
Fax Number	:

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

Provider Enumeration Date	:	07/19/2008
Last Update Date	:	02/22/2009

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