Provider Demographics
NPI:1083459663
Name:MOLLITIAM THERAPY CENTER LLC
Entity type:Organization
Organization Name:MOLLITIAM THERAPY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:GISELLE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:787-362-0367
Mailing Address - Street 1:PO BOX 1504
Mailing Address - Street 2:
Mailing Address - City:FAJARDO
Mailing Address - State:PR
Mailing Address - Zip Code:00738-9998
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CARRETERA PR 3 KM. 27.0, BARRIO JIMENEZ
Practice Address - Street 2:
Practice Address - City:RIO GRANDE
Practice Address - State:PR
Practice Address - Zip Code:00745
Practice Address - Country:US
Practice Address - Phone:939-465-1469
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-26
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty