Provider Demographics
NPI:1134289010
Name:FONTANET AVILES, MARIECARMEN (OT)
Entity type:Individual
Prefix:
First Name:MARIECARMEN
Middle Name:
Last Name:FONTANET AVILES
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PMB 2105 P O BOX 4956
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00726-4956
Mailing Address - Country:US
Mailing Address - Phone:787-744-4824
Mailing Address - Fax:787-743-0451
Practice Address - Street 1:CARR 189 KM 3 HM 6
Practice Address - Street 2:BARRIO RINCON LOTE #7
Practice Address - City:GURABO
Practice Address - State:PR
Practice Address - Zip Code:00778
Practice Address - Country:US
Practice Address - Phone:787-744-4824
Practice Address - Fax:787-743-0451
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR476225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0022426Medicare ID - Type UnspecifiedOCCUPATIONAL THERAPIST