Healthcare Provider Details

I. General information

NPI: 1922516004
Provider Name (Legal Business Name): DIANA TERESA DOMENECH PSIC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2018
Last Update Date: 01/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MO17 PASEO DEL VALLE
BAYAMON PR
00961-3539
US

IV. Provider business mailing address

MO17 PASEO DEL VALLE
BAYAMON PR
00961-3539
US

V. Phone/Fax

Practice location:
  • Phone: 787-467-8878
  • Fax:
Mailing address:
  • Phone: 787-467-8878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number5920
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: