Healthcare Provider Details

I. General information

NPI: 1811150774
Provider Name (Legal Business Name): ADVANCE THERAPY GROUP PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2008
Last Update Date: 11/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

STREET 189 MARINA PLAZA SUITE 17-18
GURABO PR
00778
US

IV. Provider business mailing address

HC 1 BOX 26910
CAGUAS PR
00725-8933
US

V. Phone/Fax

Practice location:
  • Phone: 787-948-2866
  • Fax: 787-737-6493
Mailing address:
  • Phone: 787-948-2866
  • Fax: 787-737-6493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number763
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number983
License Number StatePR
# 3
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number1449-1
License Number StatePR
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number824
License Number StatePR

VIII. Authorized Official

Name: MS. NYDIA GONZALEZ LOPEZ
Title or Position: DIRECTOR
Credential:
Phone: 787-948-2866