Provider Demographics
NPI:1083181127
Name:MUNOZ MATA, FERSSEN ELIASIN (DOCTOR IN PSYCHOLOGY)
Entity Type:Individual
Prefix:DR
First Name:FERSSEN
Middle Name:ELIASIN
Last Name:MUNOZ MATA
Suffix:
Gender:M
Credentials:DOCTOR IN PSYCHOLOGY
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Mailing Address - Street 1:GRAN VISTA 1
Mailing Address - Street 2:CALLE EL PRADO #66
Mailing Address - City:GURABO
Mailing Address - State:PR
Mailing Address - Zip Code:00778
Mailing Address - Country:US
Mailing Address - Phone:787-633-3656
Mailing Address - Fax:
Practice Address - Street 1:388 ZONA IND REPARADA 2
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716-2347
Practice Address - Country:US
Practice Address - Phone:787-812-2525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-26
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PR390200000X
PR7031103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program