MEDICARE: DR. IVELISSE NEGRON PSY. D.

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	2770	PR

General Provider Information

NPI Number	:	1700052875
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IVELISSE NEGRON PSY. D.

Provider Business Mailing Address
First Line	:	200 AVE RAFAEL CORDERO
Second Line	:	STE. 140 PMB 103
City	:	CAGUAS
State	:	PR
Zip	:	00725-3740
Country	:	US
Telephone Number	:	787-743-0709
Fax Number	:	787-745-2992

Provider Business Practice Location Address
First Line	:	200 AVE RAFAEL CORDERO
Second Line	:	STE. 140 PMB 103
City	:	CAGUAS
State	:	PR
Zip	:	00725-3740
Country	:	US
Telephone Number	:	787-743-0709
Fax Number	:	787-745-2992

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

Provider Enumeration Date	:	05/07/2008
Last Update Date	:	05/07/2008

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