1730392903 NPI number — DR. MINERVA MARTINEZ CRUZ PSICOLOGA

Table of content: DR. MINERVA MARTINEZ CRUZ PSICOLOGA (NPI 1730392903)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730392903 NPI number — DR. MINERVA MARTINEZ CRUZ PSICOLOGA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTINEZ CRUZ
Provider First Name:
MINERVA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSICOLOGA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730392903
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/17/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
426 WOBURN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEWKSBURY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01876-3437
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-238-5167
Provider Business Mailing Address Fax Number:
787-778-3113

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CENTRO PSICOLOGICO Y EDUCATIVO
Provider Second Line Business Practice Location Address:
AVE GILBERTO CONCEPCION DE GRACIA #7 3 STE 2
Provider Business Practice Location Address City Name:
SIERRA BAYAMON
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00961
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-778-3113
Provider Business Practice Location Address Fax Number:
787-778-3113
Provider Enumeration Date:
05/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  1677 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 117693600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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