Healthcare Provider Details

I. General information

NPI: 1346978962
Provider Name (Legal Business Name): WANDA I. IZQUIERDO VALLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2022
Last Update Date: 09/01/2022
Certification Date: 09/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 COSTA NORTE ESTRELLA DE MAR 226
HATILLO PR
00659-0065
US

IV. Provider business mailing address

226 CALLE ESTRELLA DE MAR # 226
HATILLO PR
00659-2747
US

V. Phone/Fax

Practice location:
  • Phone: 787-310-5821
  • Fax:
Mailing address:
  • Phone: 787-310-5821
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2067
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: