Provider Demographics
NPI:1003453069
Name:PEREZ-MARTINEZ, KRYSTAL LEE (MSW)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:LEE
Last Name:PEREZ-MARTINEZ
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 CALLE ANGELITO NIEVES
Mailing Address - Street 2:
Mailing Address - City:AGUADILLA
Mailing Address - State:PR
Mailing Address - Zip Code:00603-5819
Mailing Address - Country:US
Mailing Address - Phone:787-902-7202
Mailing Address - Fax:
Practice Address - Street 1:2600 CALLE LEDESMA
Practice Address - Street 2:
Practice Address - City:UTUADO
Practice Address - State:PR
Practice Address - Zip Code:00641
Practice Address - Country:US
Practice Address - Phone:787-433-2828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR153051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR15305Medicaid