Healthcare Provider Details

I. General information

NPI: 1700324092
Provider Name (Legal Business Name): PSICODRAMA PR CP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2017
Last Update Date: 02/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR 2 KM 156.5 510 AVE HOSTOS VISTA VERDE PLAZA SUITE A-12A
MAYAGUEZ PR
00681
US

IV. Provider business mailing address

7 LAS CASONAS
AGUADA PR
00602-9221
US

V. Phone/Fax

Practice location:
  • Phone: 788-975-2710
  • Fax:
Mailing address:
  • Phone: 787-975-2710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number14054
License Number StatePR

VIII. Authorized Official

Name: DR. VANNESSA PAGAN
Title or Position: PRESIDENT
Credential: MD
Phone: 17874005436