Provider Demographics
NPI:1992143283
Name:INNOVATIONS PSYCHOTHERAPEUTIC GROUP, PSC
Entity type:Organization
Organization Name:INNOVATIONS PSYCHOTHERAPEUTIC GROUP, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:FRANCISCO
Authorized Official - Last Name:LUNA
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:939-865-9653
Mailing Address - Street 1:142 CALLE JOSE C BARBOSA
Mailing Address - Street 2:
Mailing Address - City:MOCA
Mailing Address - State:PR
Mailing Address - Zip Code:00676-4105
Mailing Address - Country:US
Mailing Address - Phone:939-865-9653
Mailing Address - Fax:787-877-6844
Practice Address - Street 1:142 CALLE JOSE C BARBOSA
Practice Address - Street 2:
Practice Address - City:MOCA
Practice Address - State:PR
Practice Address - Zip Code:00676-4105
Practice Address - Country:US
Practice Address - Phone:939-865-9653
Practice Address - Fax:787-877-6844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-07
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4567103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty