Healthcare Provider Details

I. General information

NPI: 1811139942
Provider Name (Legal Business Name): CENTRO INTERDISCIPLINARIO PSICOEDUCATIVO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2009
Last Update Date: 04/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

URB VILLA GRILLASCA CALLE VIRGELIO BIAGGI 906
PONCE PR
00717
US

IV. Provider business mailing address

VILLA GRILLASRA 906 VIRGILIO BIAGGI
PONCE PR
00717
US

V. Phone/Fax

Practice location:
  • Phone: 787-840-7928
  • Fax:
Mailing address:
  • Phone: 787-840-7928
  • Fax: 787-290-2475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number032
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number558
License Number StatePR
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number803
License Number StatePR

VIII. Authorized Official

Name: SARAH V BAEZ
Title or Position: DIRECTOR
Credential: CLINICAL PSYCHOLOGIS
Phone: 787-840-7928