=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205535077
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEAN CARLO GARCIA-CARMONA LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2023
-----------------------------------------------------
Last Update Date | 03/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | K-31 2ND STREET PRADOS DEL SONADOR
-----------------------------------------------------
City | SANTA ISABEL
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-366-6088
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10402 CALLE ATARDECER
-----------------------------------------------------
City | VILLALBA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00766-2337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-366-6088
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 13703
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------