Healthcare Provider Details

I. General information

NPI: 1548048796
Provider Name (Legal Business Name): SPEECH & DEVELOPMENT CLINIC, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2023
Last Update Date: 09/19/2023
Certification Date: 09/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BO. MALPASO CARR. 417 KM 2.3
AGUADA PR
00602
US

IV. Provider business mailing address

HC 60 BOX 15324
AGUADA PR
00602-9273
US

V. Phone/Fax

Practice location:
  • Phone: 939-235-0543
  • Fax:
Mailing address:
  • Phone: 939-235-0543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MRS. ISAMAR LORENZO LORENZO
Title or Position: PRESIDENT
Credential: SLP
Phone: 939-235-0543