Healthcare Provider Details

I. General information

NPI: 1245120385
Provider Name (Legal Business Name): FUNDACION EDUCATIVA CONCEPCION MARTIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2025
Last Update Date: 07/09/2025
Certification Date: 07/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 CALLE DIEGO ZALDUONDO
FAJARDO PR
00738-4758
US

IV. Provider business mailing address

PO BOX 70006
FAJARDO PR
00738-7006
US

V. Phone/Fax

Practice location:
  • Phone: 787-863-3553
  • Fax:
Mailing address:
  • Phone: 787-863-3553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. IVELISSE MARIE DAVILA
Title or Position: EXECUTIVE DIRECTOR
Credential: ED.DR.
Phone: 787-863-3553