Healthcare Provider Details

I. General information

NPI: 1154684306
Provider Name (Legal Business Name): LOURDES MANTILLA MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2012
Last Update Date: 06/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BUZON 5- 186 GALATEO ALTO
ISABELA PR
00662
US

IV. Provider business mailing address

SECTOR GALATEO ALTO BUZON 186 RUTA 5
ISABELA PR
00662
US

V. Phone/Fax

Practice location:
  • Phone: 787-518-2773
  • Fax:
Mailing address:
  • Phone: 787-518-2773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number17232
License Number StatePR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier17232
Identifier TypeOTHER
Identifier StatePR
Identifier IssuerSOCIAL WORKER LIC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: