Healthcare Provider Details

I. General information

NPI: 1730714593
Provider Name (Legal Business Name): BRAIN BASE THERAPY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2020
Last Update Date: 11/07/2020
Certification Date: 11/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BARRIO LOS LLANOS CARRETERA #14, KM 26.7
COAMO PR
00769
US

IV. Provider business mailing address

URB. COLINAS DE VERDE AZUL CALLE SIENA # 46
JUANA DIAZ PR
00795
US

V. Phone/Fax

Practice location:
  • Phone: 787-202-5530
  • Fax:
Mailing address:
  • Phone: 787-202-5530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LIZA ROBELY RODRIGUEZ
Title or Position: PRESIDENTA
Credential: THL, CPETE, CNSL
Phone: 787-202-5530