Healthcare Provider Details

I. General information

NPI: 1003188244
Provider Name (Legal Business Name): EOS: PSYCHOLOGICAL WELLNESS CENTRE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2012
Last Update Date: 02/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AVE MONSERRATE AB 18 LOCAL 4 VALLE ARRIBA HEIGHTS
CAROLINA PR
00985
US

IV. Provider business mailing address

CALLE 31 AF 24 URB. INTERAMERICANA
TRUJILLO ALTO PR
00976
US

V. Phone/Fax

Practice location:
  • Phone: 787-550-9708
  • Fax:
Mailing address:
  • Phone: 787-550-9708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number4105
License Number StatePR

VIII. Authorized Official

Name: DR. AGNES SYBEL DIAZ
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PH.D.
Phone: 787-550-9708