MEDICARE: MARVIN MARQUEZ GONZALEZ PSYD

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	103TC2200X	Clinical Child & Adolescent Psychologist	7570	PR
2	103TS0200X	School Psychologist	7570	PR
3	103TC0700X	Clinical Psychologist	7570	PR

General Provider Information

NPI Number	:	1487342358
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARVIN MARQUEZ GONZALEZ PSYD

Provider Business Mailing Address
First Line	:	PO BOX 1889
Second Line	:
City	:	PONCE
State	:	PR
Zip	:	00728-1889
Country	:	US
Telephone Number	:	939-368-0578
Fax Number	:

Provider Business Practice Location Address
First Line	:	CALLE #1 995 METRO MEDICAL CENTER SUITE 801-A
Second Line	:
City	:	BAYAMON
State	:	PR
Zip	:	00959-9998
Country	:	US
Telephone Number	:	939-368-0578
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/27/2023
Last Update Date	:	10/15/2024

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