Healthcare Provider Details

I. General information

NPI: 1336668490
Provider Name (Legal Business Name): LUIS MANUEL GONZALEZ LIENCIADO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2017
Last Update Date: 09/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2U5 AVE LAUREL
BAYAMON PR
00956-3340
US

IV. Provider business mailing address

100 CALLE 220 APT 109
CAROLINA PR
00982-2802
US

V. Phone/Fax

Practice location:
  • Phone: 787-233-2747
  • Fax:
Mailing address:
  • Phone: 787-233-2747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number001198
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: