Healthcare Provider Details

I. General information

NPI: 1235593484
Provider Name (Legal Business Name): PRIME SUPPORT GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2016
Last Update Date: 09/28/2020
Certification Date: 09/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 CALLE BLOQUE 89 - 1 URB. VILLA CAROLINA
CAROLINA PR
00985
US

IV. Provider business mailing address

99 CALLE BLOQUE 89 - 1 URB. VILLA CAROLINA
CAROLINA PR
00985
US

V. Phone/Fax

Practice location:
  • Phone: 787-360-1859
  • Fax:
Mailing address:
  • Phone: 787-769-2369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: STEVEN DALMAU
Title or Position: PRESIDENT
Credential:
Phone: 787-769-2369