Healthcare Provider Details

I. General information

NPI: 1306279096
Provider Name (Legal Business Name): MARIA M ROMAN CARLO LICENSED
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2013
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DR. BASORA 55-N EDIFICIO MEDICO IV -210
MAYAGUEZ PR
00680
US

IV. Provider business mailing address

PO BOX 185
CABO ROJO PR
00623-0185
US

V. Phone/Fax

Practice location:
  • Phone: 787-210-1102
  • Fax:
Mailing address:
  • Phone: 787-222-9129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number004711
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number004711
License Number StatePR
# 3
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number004711
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: