MEDICARE: JOEL JESUS RIVERA SERRANO MA

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	103TC1900X	Counseling Psychologist	6279	PR

General Provider Information

NPI Number	:	1689220600
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOEL JESUS RIVERA SERRANO MA

Provider Business Mailing Address
First Line	:	PO BOX 1555
Second Line	:
City	:	LAS PIEDRAS
State	:	PR
Zip	:	00771-1555
Country	:	US
Telephone Number	:	787-433-6270
Fax Number	:

Provider Business Practice Location Address
First Line	:	ITURREGUI PLAZA SHOPPING CENTER
Second Line	:	1134 65TH INFANTRY AVE
City	:	CAROLINA
State	:	PR
Zip	:	00924
Country	:	US
Telephone Number	:	787-769-7100
Fax Number	:

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

Provider Enumeration Date	:	08/15/2019
Last Update Date	:	08/15/2019

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