Provider Demographics
NPI:1861057580
Name:INNOVA PSYCHOLOGICAL GROUP, LLC
Entity type:Organization
Organization Name:INNOVA PSYCHOLOGICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:GONZALEZ RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:939-545-5241
Mailing Address - Street 1:500 AVE WEST MAIN APT 215
Mailing Address - Street 2:
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00961-3875
Mailing Address - Country:US
Mailing Address - Phone:787-315-6034
Mailing Address - Fax:
Practice Address - Street 1:CARR 695 KM 2.0
Practice Address - Street 2:BO HIGUILLAR
Practice Address - City:DORADO
Practice Address - State:PR
Practice Address - Zip Code:00646
Practice Address - Country:US
Practice Address - Phone:787-315-6034
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-08
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty