Provider Demographics
NPI:1194203000
Name:DASTA-VALENTIN, ITZAMAR (OTR)
Entity Type:Individual
Prefix:
First Name:ITZAMAR
Middle Name:
Last Name:DASTA-VALENTIN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 2 BOX 16371
Mailing Address - Street 2:
Mailing Address - City:ARECIBO
Mailing Address - State:PR
Mailing Address - Zip Code:00612-9382
Mailing Address - Country:US
Mailing Address - Phone:787-213-6509
Mailing Address - Fax:
Practice Address - Street 1:2 CARR PUERTO RICO 2
Practice Address - Street 2:
Practice Address - City:HATILLO
Practice Address - State:PR
Practice Address - Zip Code:00659
Practice Address - Country:US
Practice Address - Phone:787-915-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225XP0019X
PR225XP0200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics