Healthcare Provider Details

I. General information

NPI: 1023561230
Provider Name (Legal Business Name): MENTE ACTIVA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2016
Last Update Date: 04/17/2021
Certification Date: 04/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 CALLE CAOBA CENTRO COMERCIAL LOS CAOBOS, SUITE 10
PONCE PR
00716-2610
US

IV. Provider business mailing address

775 CALLE CAOBA CENTRO COMERCIAL LOS CAOBOS, SUITE 10
PONCE PR
00716-2610
US

V. Phone/Fax

Practice location:
  • Phone: 787-677-0503
  • Fax:
Mailing address:
  • Phone: 787-677-0503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number
License Number State

VIII. Authorized Official

Name: DR. JAISSELLE MARIE VEGA
Title or Position: EXECUTIVE DIRECTOR
Credential: PHD
Phone: 787-677-0503