Healthcare Provider Details

I. General information

NPI: 1124161567
Provider Name (Legal Business Name): JOSE A REBOLLO PORTELA MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 09/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 CALLE SANTA CRUZ
BAYAMON PR
00961
US

IV. Provider business mailing address

2006 CALLE GUSTAVO BECQUER URB EL SENORIAL
SAN JUAN PR
00926-6946
US

V. Phone/Fax

Practice location:
  • Phone: 787-778-2800
  • Fax: 787-778-2801
Mailing address:
  • Phone: 787-461-6773
  • Fax: 787-778-2801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2645
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: