Healthcare Provider Details

I. General information

NPI: 1750940094
Provider Name (Legal Business Name): CASA LA PROVIDENCIA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 CALLE NORZAGARAY
SAN JUAN PR
00901-1122
US

IV. Provider business mailing address

200 CALLE NORZAGARAY
SAN JUAN PR
00901-1122
US

V. Phone/Fax

Practice location:
  • Phone: 787-725-5358
  • Fax:
Mailing address:
  • Phone: 787-725-5358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: DR. JONATHAN ECHEVARRIA
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PSY.D.
Phone: 787-725-5358