Healthcare Provider Details

I. General information

NPI: 1164062410
Provider Name (Legal Business Name): MRS. MAYRA E. DAVILA RIVERA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2020
Last Update Date: 01/14/2020
Certification Date: 01/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AVE: MONTE CARLO # 34354 PARCELA B FINCA MARIEM
SAN JUAN PR
00929-1194
US

IV. Provider business mailing address

PO BOX 30194
SAN JUAN PR
00929-1194
US

V. Phone/Fax

Practice location:
  • Phone: 787-608-0652
  • Fax:
Mailing address:
  • Phone: 787-608-0652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6479
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: