Healthcare Provider Details

I. General information

NPI: 1255662672
Provider Name (Legal Business Name): LOURDES MORENO MARTINEZ PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2010
Last Update Date: 05/14/2020
Certification Date: 05/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE TOMAS DAVILA MARTINEZ 1
BARCELONETA PR
00617
US

IV. Provider business mailing address

PO BOX 901
BARCELONETA PR
00617-0901
US

V. Phone/Fax

Practice location:
  • Phone: 787-370-7370
  • Fax:
Mailing address:
  • Phone: 787-370-7370
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3602
License Number StatePR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierII799Y
Identifier TypeMEDICAID
Identifier StatePR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: