Healthcare Provider Details

I. General information

NPI: 1790414530
Provider Name (Legal Business Name): PSIDEP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2022
Last Update Date: 06/07/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MOCA MEDICAL PLAZA #113 CARR 110 KM 12.4
MOCA PR
00676
US

IV. Provider business mailing address

PO BOX 1106
MOCA PR
00676-1106
US

V. Phone/Fax

Practice location:
  • Phone: 787-546-7508
  • Fax:
Mailing address:
  • Phone: 787-546-7508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: ABDIEL MUNIZ VERA
Title or Position: DIRECTOR
Credential: DR
Phone: 787-546-7508