Provider Demographics
NPI:1760244248
Name:DOMENECH GUTIERREZ, ROSAURA (MSW)
Entity Type:Individual
Prefix:
First Name:ROSAURA
Middle Name:
Last Name:DOMENECH GUTIERREZ
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 1:2044 CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:ISABELA
Mailing Address - State:PR
Mailing Address - Zip Code:00662
Mailing Address - Country:US
Mailing Address - Phone:939-339-2082
Mailing Address - Fax:787-551-4119
Practice Address - Street 1:BUEN SAMARITANO MEDICAL & PROFESSIONAL PLAZA
Practice Address - Street 2:TERCER PISO SUITE 11
Practice Address - City:AGUADILLA
Practice Address - State:PR
Practice Address - Zip Code:00603
Practice Address - Country:US
Practice Address - Phone:787-422-2595
Practice Address - Fax:787-551-4119
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-29
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR162061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty