Healthcare Provider Details

I. General information

NPI: 1528330362
Provider Name (Legal Business Name): PSICSUR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2012
Last Update Date: 02/08/2012
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 Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number3500
License Number StatePR

VIII. Authorized Official

Name: DR. JOSE ANGEL GANDIA
Title or Position: COORDINADOR GENERAL
Credential: PH.D. CLINICAL PSY.
Phone: 787-485-6348