Basic Information
Provider Information | |||||||||
NPI: | 1477215622 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VELEZ LOPEZ | ||||||||
FirstName: | LUSILA | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | ESTANCIAS TALAVERA 1 | ||||||||
Address2: | 7724 CALLE TUCAN | ||||||||
City: | ISABELA | ||||||||
State: | PR | ||||||||
PostalCode: | 00662 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7872010023 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | CARR. #2 KM 81.5 BO CARRIZALES | ||||||||
Address2: |   | ||||||||
City: | HATILLO | ||||||||
State: | PR | ||||||||
PostalCode: | 006590065 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7879153000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/05/2021 | ||||||||
LastUpdateDate: | 10/05/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/22/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2355S0801X | 7573 | PR | Y |   | Speech, Language and Hearing Service Providers | Specialist/Technologist | Speech-Language Assistant |
ID Information
ID | Type | State | Issuer | Description | 6745561 | 01 | PR | DRIVERS LICENSE | OTHER |