Healthcare Provider Details

I. General information

NPI: 1003589425
Provider Name (Legal Business Name): BRENDA MICHELLE ANGLADA RIVERA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2021
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 CALLE BALDORIOTY
COAMO PR
00769-2344
US

IV. Provider business mailing address

PO BOX 386
SANTA ISABEL PR
00757-0386
US

V. Phone/Fax

Practice location:
  • Phone: 787-614-3205
  • Fax:
Mailing address:
  • Phone: 787-319-2659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6958
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: