Healthcare Provider Details

I. General information

NPI: 1376992180
Provider Name (Legal Business Name): LOURDES VANESSA MATOS GONZALEZ CSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2016
Last Update Date: 02/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

URB. VALLE ALTO 1531 ALTURA
PONCE PUERTO RICO
00730
UM

IV. Provider business mailing address

URB. VALLE ALTO 1531 ALTURA
PONCE PUERTO RICO
00730
UM

V. Phone/Fax

Practice location:
  • Phone: 787-202-4789
  • Fax:
Mailing address:
  • Phone: 787-202-4789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13420
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: