Healthcare Provider Details

I. General information

NPI: 1487161808
Provider Name (Legal Business Name): MENTE RENOVADA CENTRO DE INTERVENCION CLINICA SOCIAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2018
Last Update Date: 08/05/2025
Certification Date: 07/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BUEN SAMARITANO MEDICAL & PROFESSIONAL PLAZA TERCER PISO SUITE #11
AGUADILLA PR
00603
US

IV. Provider business mailing address

219 CALLE A
AGUADA PR
00602-4007
US

V. Phone/Fax

Practice location:
  • Phone: 787-422-2595
  • Fax:
Mailing address:
  • Phone: 787-669-5124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number10474
License Number StatePR

VIII. Authorized Official

Name: MRS. MARIAN DESARDEN
Title or Position: TRABAJADORA SOCIAL CLINICA
Credential: LICENCIADA
Phone: 787-422-2595