Healthcare Provider Details

I. General information

NPI: 1689220600
Provider Name (Legal Business Name): JOEL JESUS RIVERA SERRANO MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2019
Last Update Date: 08/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ITURREGUI PLAZA SHOPPING CENTER 1134 65TH INFANTRY AVE
CAROLINA PR
00924
US

IV. Provider business mailing address

PO BOX 1555
LAS PIEDRAS PR
00771-1555
US

V. Phone/Fax

Practice location:
  • Phone: 787-769-7100
  • Fax:
Mailing address:
  • Phone: 787-433-6270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6279
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: