Healthcare Provider Details

I. General information

NPI: 1225530405
Provider Name (Legal Business Name): LYCELIZ HERNANDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2018
Last Update Date: 03/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 URB CATALANA
BARCELONETA PR
00617-0061
US

IV. Provider business mailing address

PO BOX 59
MOCA PR
00676
US

V. Phone/Fax

Practice location:
  • Phone: 787-915-3000
  • Fax:
Mailing address:
  • Phone: 787-392-9066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2039
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: