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General NPI Number Information
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NPI Number | 1972189298
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Entity Type | Organization
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Legal Business Name | MANTIS WELLNESS CENTER LLC
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Dates
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Enumeration Date | 03/18/2021
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Last Update Date | 03/18/2021
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Provider Practice Location Address
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Address Line | URB FLAMINGO TERRACE A7 MARG 167
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City | BAYAMON
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State | PR
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Zip | 00957
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Country | US
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Telephone | 787-981-3037
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Fax |
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Provider Business Mailing Address
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Address Line | URB FLAMINGO TERRACE A7 MARG 167
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City | BAYAMON
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State | PR
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Zip | 00957
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Country | US
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Telephone | 787-981-3037
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Fax |
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Authorized Official
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Title or Position | ADMINISTRADOR
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Name | MR. FERNANDO RODRIGUEZ NIEVES
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Credential | BA
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Telephone | 787-360-9657
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 103TS0200X
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Taxonomy Name | School Psychologist
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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