Provider Demographics
NPI:1255662672
Name:MORENO MARTINEZ, LOURDES (PHD)
Entity Type:Individual
Prefix:DR
First Name:LOURDES
Middle Name:
Last Name:MORENO MARTINEZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 901
Mailing Address - Street 2:
Mailing Address - City:BARCELONETA
Mailing Address - State:PR
Mailing Address - Zip Code:00617-0901
Mailing Address - Country:US
Mailing Address - Phone:787-370-7370
Mailing Address - Fax:
Practice Address - Street 1:CALLE TOMAS DAVILA MARTINEZ 1
Practice Address - Street 2:
Practice Address - City:BARCELONETA
Practice Address - State:PR
Practice Address - Zip Code:00617
Practice Address - Country:US
Practice Address - Phone:787-370-7370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-25
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3602103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRII799YMedicaid