Healthcare Provider Details

I. General information

NPI: 1851861066
Provider Name (Legal Business Name): NILSA COLLAZO PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2018
Last Update Date: 04/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR 135 KM 64.2
CASTANER PR
00631
US

IV. Provider business mailing address

308 CALLE JUAN H CINTRON
PONCE PR
00730-0515
US

V. Phone/Fax

Practice location:
  • Phone: 787-829-5010
  • Fax: 787-544-3860
Mailing address:
  • Phone: 787-439-9427
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2104
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: