MEDICARE: INNOVATION MENTAL HEALTH SERVICES CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TH0100X	Health Service Psychologist	2465	PR

General Provider Information

NPI Number	:	1063866440
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATION MENTAL HEALTH SERVICES CORP

Provider Business Mailing Address
First Line	:	AVE DEGETAU
Second Line	:	URB. BONEVILLE HEIGHTS V-18
City	:	CAGUAS
State	:	PR
Zip	:	00725-5819
Country	:	US
Telephone Number	:	787-665-7611
Fax Number	:

Provider Business Practice Location Address
First Line	:	AVE DEGETAU
Second Line	:	URB. BONEVILLE HEIGHTS V-18
City	:	CAGUAS
State	:	PR
Zip	:	00725-5819
Country	:	US
Telephone Number	:	787-665-7611
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL PSYCHOLOGIST
Name	:	DR. VICTOR M GONZALEZ
Credential	:	PSY.D.
Telephone Number	:	787-664-1101

Provider Enumeration Date	:	04/21/2016
Last Update Date	:	04/21/2016

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