Healthcare Provider Details

I. General information

NPI: 1619748175
Provider Name (Legal Business Name): CARLOS GUSTAVO MORENO VELEZ LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2024
Last Update Date: 01/12/2024
Certification Date: 01/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PLAZA TROPICAL MALL CARR. 167 KM.22.0
BAYAMON PR
00959
US

IV. Provider business mailing address

URBANIZACION REXVILLE CALLE 6 G-8
BAYAMON PR
00957
US

V. Phone/Fax

Practice location:
  • Phone: 787-641-0774
  • Fax:
Mailing address:
  • Phone: 787-447-6675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number16734
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: