Healthcare Provider Details

I. General information

NPI: 1083459663
Provider Name (Legal Business Name): MOLLITIAM THERAPY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2024
Last Update Date: 10/31/2025
Certification Date: 10/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARRETERA PR 3 KM. 27.0, BARRIO JIMENEZ
RIO GRANDE PR
00745
US

IV. Provider business mailing address

PO BOX 1504
FAJARDO PR
00738-9998
US

V. Phone/Fax

Practice location:
  • Phone: 939-465-1469
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: GISELLE MARIE MARTINEZ
Title or Position: SPEECH LANGUAGE PATHOLOGIST
Credential: MS, CCC-SLP
Phone: 787-362-0367