Healthcare Provider Details

I. General information

NPI: 1700157526
Provider Name (Legal Business Name): RAISA AIMME RODRIGUEZ PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2012
Last Update Date: 01/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AVE. SANCHEZ CASTANO 2DA EXT VILLA CAROLINA CALLE 18 BLQ. 22 # 2
CAROLINA PR
00985
US

IV. Provider business mailing address

COND JARDIN SERENO APT 1002
CAROLINA PR
00983
US

V. Phone/Fax

Practice location:
  • Phone: 787-637-0375
  • Fax: 787-752-8466
Mailing address:
  • Phone: 787-637-0375
  • Fax: 787-752-8466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number4189
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4189
License Number StatePR
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number4189
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: