Provider Demographics
NPI:1518289545
Name:CANON, MARTHA LUCIA (MSW)
Entity Type:Individual
Prefix:PROF
First Name:MARTHA
Middle Name:LUCIA
Last Name:CANON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:COND LAS VILLAS DE BAYAMON
Mailing Address - Street 2:AVENIDA 500 WEST MAIN, SUITE 176
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00961-3871
Mailing Address - Country:US
Mailing Address - Phone:787-269-3818
Mailing Address - Fax:
Practice Address - Street 1:LOIZA VALLEY SHOPPING CENTER, LOCAL AA-6
Practice Address - Street 2:
Practice Address - City:CANOVANAS
Practice Address - State:PR
Practice Address - Zip Code:00729
Practice Address - Country:US
Practice Address - Phone:787-256-0273
Practice Address - Fax:787-876-7856
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR59841041C0700X, 261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health