=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598118564
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SERVICIOS TERAPEUTICOS MAYARI, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2016
-----------------------------------------------------
Last Update Date | 07/14/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | SANTA ROSA MALL OFIC 202B
-----------------------------------------------------
City | BAYAMON
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00959-0000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-780-6006
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | SANTA ROSA MALL OFIC 202B
-----------------------------------------------------
City | BAYAMON
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00959
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-780-6006
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPEECH AND LANGUAGE PATHOLOGIST
-----------------------------------------------------
Name | MRS. SANDRA AISSA MATTOS
-----------------------------------------------------
Credential | MS
-----------------------------------------------------
Telephone | 787-780-6006
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 626
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 0155
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 237
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 723
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 003
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------