Healthcare Provider Details

I. General information

NPI: 1235404070
Provider Name (Legal Business Name): JOSE ANGEL GANDIA PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2012
Last Update Date: 03/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9140 CALLE MARINA SUITE 502
PONCE PR
00717
US

IV. Provider business mailing address

9140 CALLE MARINA SUITE 502
PONCE PR
00717
US

V. Phone/Fax

Practice location:
  • Phone: 787-485-6348
  • Fax:
Mailing address:
  • Phone: 787-485-6348
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3500
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number3500
License Number StatePR
# 3
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number3500
License Number StatePR
# 4
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number3500
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: