MEDICARE: MRS. ELISA M. LEBRON M.A

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	103TS0200X	School Psychologist	3575	PR

General Provider Information

NPI Number	:	1649598897
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ELISA M. LEBRON M.A

Provider Business Mailing Address
First Line	:	CONDOMINIO CORDOBA PARK 400 APTDO. 112
Second Line	:
City	:	SAN JUAN
State	:	PR
Zip	:	00926-9773
Country	:	US
Telephone Number	:	787-923-4542
Fax Number	:

Provider Business Practice Location Address
First Line	:	COND CORDOVA PARK
Second Line	:	400 BO. TORTUGO APT 112
City	:	SAN JUAN
State	:	PR
Zip	:	00926-9769
Country	:	US
Telephone Number	:	787-923-4542
Fax Number	:

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

Provider Enumeration Date	:	05/12/2010
Last Update Date	:	05/12/2010

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