Healthcare Provider Details

I. General information

NPI: 1114856267
Provider Name (Legal Business Name): IVISSELISE RIVERA BLANCO MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARRETERA 143 KM 53.9 BO HELECHAL
BARANQUITAS PR
00794-1652
US

IV. Provider business mailing address

URBANIZACION PROVINCIAS DEL RIO II #216 CALLE JACAGUAZ
COAMO PR
00769
US

V. Phone/Fax

Practice location:
  • Phone: 787-201-4853
  • Fax:
Mailing address:
  • Phone: 787-201-4853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number5545
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: