Provider Demographics
NPI:1477073203
Name:MOLINA VILLANUEVA, WISARYS
Entity Type:Individual
Prefix:
First Name:WISARYS
Middle Name:
Last Name:MOLINA VILLANUEVA
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:RR 2 BOX 3017
Mailing Address - Street 2:
Mailing Address - City:TOA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00953-9664
Mailing Address - Country:US
Mailing Address - Phone:787-464-8082
Mailing Address - Fax:
Practice Address - Street 1:465 AVE HOSTOS URB. VEDADO
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918-3014
Practice Address - Country:US
Practice Address - Phone:787-946-4501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-22
Last Update Date:2017-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4092235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist