Healthcare Provider Details

I. General information

NPI: 1831009877
Provider Name (Legal Business Name): SULLYANN KRYSTAL LOPEZ PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2610 CALLE MAYOR STE 1
PONCE PR
00717-2051
US

IV. Provider business mailing address

2610 CALLE MAYOR STE 1
PONCE PR
00717-2051
US

V. Phone/Fax

Practice location:
  • Phone: 787-514-7799
  • Fax:
Mailing address:
  • Phone: 787-514-7799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number9242
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: