Healthcare Provider Details

I. General information

NPI: 1528972494
Provider Name (Legal Business Name): ID THERAPHY GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR PR 149 KM 9.3 UNIDAD LOCAL 6 SECTOR CUCHILLAS BO HATO VIEJO
MANATI PR
00674
US

IV. Provider business mailing address

40 CALLE GAVIOTA
MANATI PR
00674-9420
US

V. Phone/Fax

Practice location:
  • Phone: 787-695-8223
  • Fax:
Mailing address:
  • Phone: 787-608-2831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateNULL

VIII. Authorized Official

Name: TOMMY QUINTERO
Title or Position: PRESIDENT
Credential:
Phone: 787-608-2831