Healthcare Provider Details

I. General information

NPI: 1477215531
Provider Name (Legal Business Name): ILIANNE MARIE LOUCIL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2021
Last Update Date: 10/06/2021
Certification Date: 10/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N28 URB JESUS M LAGO
UTUADO PR
00641-2408
US

IV. Provider business mailing address

N28 URB JESUS M LAGO
UTUADO PR
00641-2408
US

V. Phone/Fax

Practice location:
  • Phone: 787-485-3753
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number89688
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number89688
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: