MEDICARE: VILMANIA G. MAMBRU TAVAREZ PSY D

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	103T00000X	Psychologist	2488	PR

General Provider Information

NPI Number	:	1407823651
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VILMANIA G. MAMBRU TAVAREZ PSY D

Provider Business Mailing Address
First Line	:	URB VILLAS DE CAMBALACHE I
Second Line	:	N15 CEDRO STREET BUZON 112
City	:	RIO GRANDE
State	:	PR
Zip	:	00745-0000
Country	:	US
Telephone Number	:	787-887-5900
Fax Number	:

Provider Business Practice Location Address
First Line	:	URB ALTURAS DE RIO GRANDE
Second Line	:	AA5 CALLE C
City	:	RIO GRANDE
State	:	PR
Zip	:	00745-0000
Country	:	US
Telephone Number	:	787-887-5900
Fax Number	:

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

Provider Enumeration Date	:	03/07/2006
Last Update Date	:	08/17/2009

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