Provider Demographics
NPI:1639903180
Name:MONTILLA, MARA
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:
Last Name:MONTILLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CALLE RODRIGUEZ SERRA APT 702
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00907-1451
Mailing Address - Country:US
Mailing Address - Phone:787-567-4939
Mailing Address - Fax:
Practice Address - Street 1:29 CALLE WASHINGTON STE 807
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00907-1503
Practice Address - Country:US
Practice Address - Phone:787-500-1555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7984103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist