Provider Demographics
NPI:1427362805
Name:GONZALEZ-DAVILA, MYRNA
Entity Type:Individual
Prefix:
First Name:MYRNA
Middle Name:
Last Name:GONZALEZ-DAVILA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:722 CALLE PIEDRAS NEGRAS
Mailing Address - Street 2:URB VENUS GARDENS
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-4619
Mailing Address - Country:US
Mailing Address - Phone:787-640-7622
Mailing Address - Fax:
Practice Address - Street 1:722 CALLE PIEDRAS NEGRAS
Practice Address - Street 2:URB VENUS GARDENS
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926-4619
Practice Address - Country:US
Practice Address - Phone:787-640-7622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-28
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1900103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist