MEDICARE: INSTITUTO PARA EL DESARROLLO PERSONAL, INC.

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)		PR

General Provider Information

NPI Number	:	1376711028
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INSTITUTO PARA EL DESARROLLO PERSONAL, INC.

Provider Business Mailing Address
First Line	:	M31 CALLE 13
Second Line	:	CONDADO MODERNO
City	:	CAGUAS
State	:	PR
Zip	:	00725-2443
Country	:	US
Telephone Number	:	787-703-4050
Fax Number	:	787-703-4115

Provider Business Practice Location Address
First Line	:	364 CALLE SAN JORGE APT 4B
Second Line	:	CONDOMINIO LAS CARMELITAS
City	:	SAN JUAN
State	:	PR
Zip	:	00912-3318
Country	:	US
Telephone Number	:	787-632-4049
Fax Number	:	787-722-3961

Authorized Official
Title or Position	:	PRESIDENTA
Name	:	DR. GLORIA E. BAQUERO
Credential	:	ED.D
Telephone Number	:	787-703-4050

Provider Enumeration Date	:	02/15/2008
Last Update Date	:	02/15/2008

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