Provider Demographics
NPI:1568036606
Name:LUNA, MARISOL (TAC-III, TFC-III)
Entity Type:Individual
Prefix:
First Name:MARISOL
Middle Name:
Last Name:LUNA
Suffix:
Gender:F
Credentials:TAC-III, TFC-III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 46 BOX 5560
Mailing Address - Street 2:
Mailing Address - City:DORADO
Mailing Address - State:PR
Mailing Address - Zip Code:00646-9611
Mailing Address - Country:US
Mailing Address - Phone:787-462-1101
Mailing Address - Fax:
Practice Address - Street 1:COMUNIDAD WILLIAM FUERTES
Practice Address - Street 2:CALLE 3 P73 B BO PALMAS
Practice Address - City:CATANO
Practice Address - State:PR
Practice Address - Zip Code:00962
Practice Address - Country:US
Practice Address - Phone:787-462-1101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-13
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL05-20-2057101YA0400X
FL07-39-2057101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLTAC-III-05-20-2057OtherIRBO CORP.
FLTFC-III-07-39-2057OtherIRBO CORP