Provider Demographics
NPI:1164155560
Name:MARTY IRIZARRY, PRISCILLA JOANNE (MSW)
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:JOANNE
Last Name:MARTY IRIZARRY
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:PMB 102
Mailing Address - Street 2:PO BOX 5103
Mailing Address - City:CABO ROJO
Mailing Address - State:PR
Mailing Address - Zip Code:00623
Mailing Address - Country:US
Mailing Address - Phone:787-605-8310
Mailing Address - Fax:
Practice Address - Street 1:MAYAGUEZ MEDICAL CENTER
Practice Address - Street 2:CARR #2
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680
Practice Address - Country:US
Practice Address - Phone:787-832-9737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-05
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR149161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR14916OtherSOCIAL WORK PERMANENT LICENSE