Provider Demographics
NPI:1760280929
Name:GONZALEZ MOTTA, MARIAM I
Entity type:Individual
Prefix:
First Name:MARIAM
Middle Name:I
Last Name:GONZALEZ MOTTA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:MARIAM
Other - Middle Name:I
Other - Last Name:GONZALEZ MOTTA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1041 CALLE CARITE
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00725-7645
Mailing Address - Country:US
Mailing Address - Phone:787-219-7490
Mailing Address - Fax:
Practice Address - Street 1:1041 CALLE CARITE
Practice Address - Street 2:
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725-7645
Practice Address - Country:US
Practice Address - Phone:787-219-7490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-04
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7004103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist