MEDICARE: RUTH MILEIDY PAGAN CUSTODIO

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	101YM0800X	Mental Health Counselor	4532	PR

General Provider Information

NPI Number	:	1942030887
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUTH MILEIDY PAGAN CUSTODIO

Provider Business Mailing Address
First Line	:	Y4 CALLE 22
Second Line	:
City	:	CATANO
State	:	PR
Zip	:	00962-6410
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	51 CALLE LAS FLORES
Second Line	:
City	:	CATANO
State	:	PR
Zip	:	00962-4746
Country	:	US
Telephone Number	:	787-944-9626
Fax Number	:

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

Provider Enumeration Date	:	08/06/2024
Last Update Date	:	08/06/2024

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