Healthcare Provider Details

I. General information

NPI: 1033392147
Provider Name (Legal Business Name): ELIXMAHIR DAVILA-MARRERO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2007
Last Update Date: 12/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 CALLE 2 E URB. SANTA CRUZ
BAYAMON PR
00961-3516
US

IV. Provider business mailing address

RR 4 BOX 1273
BAYAMON PR
00956-9429
US

V. Phone/Fax

Practice location:
  • Phone: 787-354-6300
  • Fax:
Mailing address:
  • Phone: 787-354-6300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number2641
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2641
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: