Provider Demographics
NPI:1700135167
Name:BERRIOS LOPEZ, IVELISSE MARIE (MS SLP)
Entity Type:Individual
Prefix:MRS
First Name:IVELISSE
Middle Name:MARIE
Last Name:BERRIOS LOPEZ
Suffix:
Gender:F
Credentials:MS SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:759 AVE AVELINO VICENTE
Mailing Address - Street 2:
Mailing Address - City:SANTURCE
Mailing Address - State:PR
Mailing Address - Zip Code:00909-2538
Mailing Address - Country:US
Mailing Address - Phone:787-724-5559
Mailing Address - Fax:
Practice Address - Street 1:759 AVE AVELINO VICENTE
Practice Address - Street 2:
Practice Address - City:SANTURCE
Practice Address - State:PR
Practice Address - Zip Code:00909-2538
Practice Address - Country:US
Practice Address - Phone:787-724-5559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-31
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1904235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist