MEDICARE: DR. CARMEN LYDIA RIVERA MEDINA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	2210	PR

General Provider Information

NPI Number	:	1093220519
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CARMEN LYDIA RIVERA MEDINA

Provider Business Mailing Address
First Line	:	CHALETS DEL PARQUE
Second Line	:	12 AVE ARBOLOTE #144
City	:	GUAYNABO
State	:	PR
Zip	:	00969-5507
Country	:	US
Telephone Number	:	939-248-7323
Fax Number	:

Provider Business Practice Location Address
First Line	:	CALLE 2 E-11, SANTA CRUZ
Second Line	:
City	:	BAYAMON
State	:	PR
Zip	:	00961-3516
Country	:	US
Telephone Number	:	939-248-7323
Fax Number	:	888-251-9661

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/06/2017
Last Update Date	:	12/06/2017

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