Healthcare Provider Details

I. General information

NPI: 1104792894
Provider Name (Legal Business Name): MARITZA MERCADO LUCIANO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2025
Last Update Date: 10/11/2025
Certification Date: 10/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

K11 CALLE PUEBLO NUEVO
CABO ROJO PR
00623-3407
US

IV. Provider business mailing address

K11 CALLE PUEBLO NUEVO
CABO ROJO PR
00623-3407
US

V. Phone/Fax

Practice location:
  • Phone: 787-347-6998
  • Fax:
Mailing address:
  • Phone: 787-347-6998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101200000X
TaxonomyDrama Therapist
License Number779
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: