Provider Demographics
NPI:1710107222
Name:ROMAN RESTO, MARTA IVELISSE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARTA
Middle Name:IVELISSE
Last Name:ROMAN RESTO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ITURREGUI PLAXA
Mailing Address - Street 2:SUITE 217-A
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-0000
Mailing Address - Country:US
Mailing Address - Phone:787-768-5501
Mailing Address - Fax:787-768-8094
Practice Address - Street 1:ITURREGUI PLAXA
Practice Address - Street 2:SUITE 217-A
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926-0000
Practice Address - Country:US
Practice Address - Phone:787-768-5501
Practice Address - Fax:787-768-8094
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2809103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical