Healthcare Provider Details

I. General information

NPI: 1588690531
Provider Name (Legal Business Name): MARIELA A CUBANO PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 12/27/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

EDIFICIO PUERTA DEL NORTE MALL 22 SUITE 7
MANATI PR
00674-4999
US

IV. Provider business mailing address

URB JARDIN DORADO 21287 CALLE ROSA
DORADO PR
00646-7049
US

V. Phone/Fax

Practice location:
  • Phone: 787-621-6281
  • Fax:
Mailing address:
  • Phone: 787-621-6281
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2394
License Number StatePR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2394
Identifier TypeOTHER
Identifier StatePR
Identifier IssuerLICENCE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: