Provider Demographics
NPI:1396363800
Name:TU ESPACIO PARA CRECER, LLC
Entity Type:Organization
Organization Name:TU ESPACIO PARA CRECER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH AND LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MS
Authorized Official - First Name:MIOSSOTTYS
Authorized Official - Middle Name:
Authorized Official - Last Name:PLAZA HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:787-222-2112
Mailing Address - Street 1:388 CALLE LUQUILLO
Mailing Address - Street 2:
Mailing Address - City:VEGA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00693-6057
Mailing Address - Country:US
Mailing Address - Phone:787-222-2112
Mailing Address - Fax:
Practice Address - Street 1:388 CALLE LUQUILLO
Practice Address - Street 2:
Practice Address - City:VEGA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00693-6057
Practice Address - Country:US
Practice Address - Phone:787-222-2112
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-10
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR4082OtherLICENSE NUMBER