Healthcare Provider Details

I. General information

NPI: 1740777614
Provider Name (Legal Business Name): INSTITUTO DE DESARROLLO INTEGRAL Y EVALUACION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2018
Last Update Date: 04/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

Q-11 AVE. CHUMLEY TURABO GARDENS
CAGUAS PR
00727
US

IV. Provider business mailing address

PO BOX 5442
CAGUAS PR
00726-5442
US

V. Phone/Fax

Practice location:
  • Phone: 787-364-9880
  • Fax:
Mailing address:
  • Phone: 787-364-9880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name: DR. MARY ANN MARTINEZ
Title or Position: OWNER
Credential: NCC
Phone: 787-960-3517