Healthcare Provider Details

I. General information

NPI: 1427731538
Provider Name (Legal Business Name): CENTRO PSICOLOGICO ILO SE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2023
Last Update Date: 04/08/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66B JOSEFINA LEGRAND ESQUINA PALMER
CANOVANAS PR
00729-0000
US

IV. Provider business mailing address

SAN ALFONSO D12 CALLE MIS AMORES
CAGUAS PR
00725-5128
US

V. Phone/Fax

Practice location:
  • Phone: 787-903-9863
  • Fax:
Mailing address:
  • Phone: 787-558-8718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: IVELISSE LOPEZ
Title or Position: PRESIDENT
Credential: PSYD
Phone: 787-930-3144