=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336772649
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLINICA DE INTELIGENCIA EMOCIONAL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2020
-----------------------------------------------------
Last Update Date | 02/14/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 BLVD PIEL CANELA
-----------------------------------------------------
City | COAMO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00769-3502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 939-494-2477
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 112 CALLE REGENCIA
-----------------------------------------------------
City | COAMO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00769-9814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-672-2441
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DAMARIS GONZALEZ
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 787-672-2441
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------