Healthcare Provider Details

I. General information

NPI: 1396763561
Provider Name (Legal Business Name): CENTRO INTERDISCIPLINARIO DE SALUD MENTAL, C.S.P
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 05/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CENTRO CARIBE BUILDING 2053 PONCE BY PASS SUITE 205
PONCE PR
00717-1308
US

IV. Provider business mailing address

PO BOX 632
MERCEDITA PR
00715-0632
US

V. Phone/Fax

Practice location:
  • Phone: 787-453-8666
  • Fax: 787-841-4170
Mailing address:
  • Phone: 787-453-8666
  • Fax: 787-841-4170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2334
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number12657
License Number StatePR

VIII. Authorized Official

Name: CARLOS A LADO-CORNEJO
Title or Position: PRESIDENT
Credential: MD
Phone: 787-453-8666