Healthcare Provider Details

I. General information

NPI: 1427362805
Provider Name (Legal Business Name): MYRNA GONZALEZ-DAVILA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2010
Last Update Date: 07/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

722 CALLE PIEDRAS NEGRAS URB VENUS GARDENS
SAN JUAN PR
00926-4619
US

IV. Provider business mailing address

722 CALLE PIEDRAS NEGRAS URB VENUS GARDENS
SAN JUAN PR
00926-4619
US

V. Phone/Fax

Practice location:
  • Phone: 787-640-7622
  • Fax:
Mailing address:
  • Phone: 787-640-7622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1900
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: