=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043717507
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHIA MARIE MARIE CPL, MA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2018
-----------------------------------------------------
Last Update Date | 04/11/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CARR 198 KM 10.1 SECTOR LA FERMINA BO COTTO MABU EDIFICIO 3
-----------------------------------------------------
City | HUMACAO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00791
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-955-2105
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2175
-----------------------------------------------------
City | COAMO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00769-4175
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-955-2105
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 1254
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------