Healthcare Provider Details

I. General information

NPI: 1962733345
Provider Name (Legal Business Name): GRISELLE GARCIA HERNANDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2010
Last Update Date: 01/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 CALLE LUNA ESQUINA TORRES
PONCE PR
00730
US

IV. Provider business mailing address

PO BOX 336223
PONCE PR
00733-6223
US

V. Phone/Fax

Practice location:
  • Phone: 787-844-5364
  • Fax:
Mailing address:
  • Phone: 787-844-5364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number3547
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3547
License Number StatePR
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number3547
License Number StatePR
# 4
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number3547
License Number StatePR
# 5
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number3547
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: