=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508289471
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRACE PSYCHOLOGY CENTER CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2014
-----------------------------------------------------
Last Update Date | 01/29/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 CALLE BORINQUEN SUITE 2-1
-----------------------------------------------------
City | TRUJILLO ALTO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00976-5981
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-435-8816
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 CALLE BORINQUEN SUITE 2-1
-----------------------------------------------------
City | TRUJILLO ALTO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00976-5981
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-435-8816
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST/PRESIDENT
-----------------------------------------------------
Name | MRS. AMALID ROMAN MARQUEZ
-----------------------------------------------------
Credential | MA
-----------------------------------------------------
Telephone | 787-435-8816
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 5578
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------