Healthcare Provider Details

I. General information

NPI: 1629934666
Provider Name (Legal Business Name): MARILISSA DE JESUS LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2026
Last Update Date: 01/03/2026
Certification Date: 01/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HC 44 BOX 12949
CAYEY PR
00736-9715
US

IV. Provider business mailing address

HC 44 BOX 12949
CAYEY PR
00736-9715
US

V. Phone/Fax

Practice location:
  • Phone: 939-316-5293
  • Fax:
Mailing address:
  • Phone: 939-316-5293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number8699
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: