Basic Information
| Provider Information | |||||||||
| NPI: | 1780283887 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSA MATOS | ||||||||
| FirstName: | EMILY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROSA MATOS | ||||||||
| OtherFirstName: | EMILY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PHD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | HC 2 BOX 5772 | ||||||||
| Address2: | |||||||||
| City: | COMERIO | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007829667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7879250254 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | STATE ROAD 14 | ||||||||
| Address2: | CALLE SARGENTO GERARDO SANTIAGO #15 | ||||||||
| City: | AIBONITO | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877142462 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2020 | ||||||||
| LastUpdateDate: | 11/27/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 6701 | PR | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 4603788 | 01 | PR | DRIVER LICENSE | OTHER | 6701 | 01 | PR | PROFESSIONAL LICENSE | OTHER |