Healthcare Provider Details

I. General information

NPI: 1780360644
Provider Name (Legal Business Name): JULIO JUAN RIVERA BAEZ SR. MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2023
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SVS PLAZA I LOCAL #208 CARR. #2KM 149.5, BO. ALGAROBO
MAYAGUEZ PR
00682
US

IV. Provider business mailing address

URB. MONTE SOL CALLE JUPITER 207
YAUCO PR
00698
US

V. Phone/Fax

Practice location:
  • Phone: 939-222-7087
  • Fax:
Mailing address:
  • Phone: 939-400-1683
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number007425
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number007425
License Number StatePR
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number007425
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: