Healthcare Provider Details

I. General information

NPI: 1063376127
Provider Name (Legal Business Name): STEPHANIE LYNNE MORENO LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2025
Last Update Date: 12/12/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

TOSCANA DE GURABO CALLE GENNOVA # 176
GURABO PR
00778
US

IV. Provider business mailing address

P6 CALLE JESUS ALLENDE
CAROLINA PR
00987-6819
US

V. Phone/Fax

Practice location:
  • Phone: 787-233-3282
  • Fax:
Mailing address:
  • Phone: 787-233-3282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number8799
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: