Healthcare Provider Details

I. General information

NPI: 1528786613
Provider Name (Legal Business Name): EMANUEL MONTALVO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2022
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SANTA MARIA SHOPPING CTR
PONCE PR
00717-4199
US

IV. Provider business mailing address

PO BOX 1006
LAJAS PR
00667-1006
US

V. Phone/Fax

Practice location:
  • Phone: 787-813-2324
  • Fax:
Mailing address:
  • Phone: 787-512-1409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number7391
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: