Provider Demographics
NPI:1144664897
Name:ABRAZO DE ANGEL THERAPY GROUP
Entity type:Organization
Organization Name:ABRAZO DE ANGEL THERAPY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO- OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARANYELIZ
Authorized Official - Middle Name:IVETTE
Authorized Official - Last Name:OLIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:OTA
Authorized Official - Phone:787-946-9995
Mailing Address - Street 1:CALLE BORI 1528 (MARGINAL CARR. PR-1)
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00927-6116
Mailing Address - Country:US
Mailing Address - Phone:787-946-9995
Mailing Address - Fax:
Practice Address - Street 1:CALLE BORI 1528
Practice Address - Street 2:LOCAL 'A'
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00927-6116
Practice Address - Country:US
Practice Address - Phone:787-946-9995
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-24
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251C00000X
PR4845804235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled ServicesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR4359634Medicaid