Healthcare Provider Details

I. General information

NPI: 1528668845
Provider Name (Legal Business Name): MARLYNE LOPEZ PANTOJA PSY.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2020
Last Update Date: 03/03/2021
Certification Date: 02/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR. #2 KM 55.2 BO. PALENQUE
BARCELONETA PR
00617
US

IV. Provider business mailing address

URB. MONSERRATE C/ GOLONDRINA G-2 #504
MANATI PR
00674
US

V. Phone/Fax

Practice location:
  • Phone: 787-420-0270
  • Fax:
Mailing address:
  • Phone: 787-420-0270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6657
License Number StatePR

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: