Healthcare Provider Details

I. General information

NPI: 1417442310
Provider Name (Legal Business Name): PSYCHOLOGY CASTRO LEBRON PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2018
Last Update Date: 06/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

168 AVE BARBOSA
CATANO PR
00962-4782
US

IV. Provider business mailing address

A15 CALLE BRAZIL URB EL JARDIN
GUAYNABO PR
00969
US

V. Phone/Fax

Practice location:
  • Phone: 939-262-8213
  • Fax:
Mailing address:
  • Phone: 939-262-8213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. IVELISSE L CASTRO LEBRON
Title or Position: PRESIDENT
Credential: PSYD
Phone: 939-262-8213