Healthcare Provider Details

I. General information

NPI: 1457049405
Provider Name (Legal Business Name): CRISTINA DEL MAR HEREDIA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2023
Last Update Date: 04/27/2023
Certification Date: 04/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 AVE HOSTOS STE 7
MAYAGUEZ PR
00682-1500
US

IV. Provider business mailing address

410 AVE HOSTOS STE 7
MAYAGUEZ PR
00682-1500
US

V. Phone/Fax

Practice location:
  • Phone: 787-833-0663
  • Fax:
Mailing address:
  • Phone: 787-833-0663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number14315
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: