Provider Demographics
NPI:1306225248
Name:INNOVATION MENTAL HEALTH SERVICES CORP
Entity Type:Organization
Organization Name:INNOVATION MENTAL HEALTH SERVICES CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:M
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:787-664-1101
Mailing Address - Street 1:5 CALLE
Mailing Address - Street 2:REPARTO MONTELLANO
Mailing Address - City:CAYEY
Mailing Address - State:PR
Mailing Address - Zip Code:00736
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5 CALLE
Practice Address - Street 2:REPARTO MONTELLANO
Practice Address - City:CAYEY
Practice Address - State:PR
Practice Address - Zip Code:00736-4201
Practice Address - Country:US
Practice Address - Phone:787-664-1101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-26
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2465103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR103TH0100XMedicaid
PR103TH0100XMedicare UPIN
PR103TH0100XMedicaid
PR103TH0100XMedicare PIN