Healthcare Provider Details

I. General information

NPI: 1093533648
Provider Name (Legal Business Name): GENESIS D. ESPAILLAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2024
Last Update Date: 10/02/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE MAGA, BARRIO MONACILLO
SAN JUAN PR
00922
US

IV. Provider business mailing address

PO BOX 6899
SAN JUAN PR
00914-6899
US

V. Phone/Fax

Practice location:
  • Phone: 787-766-4646
  • Fax:
Mailing address:
  • Phone: 787-530-2577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number16910
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: