Healthcare Provider Details

I. General information

NPI: 1497984207
Provider Name (Legal Business Name): CENTRO DE SERVICIOS PSICOLOGICOS DEL OESTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2009
Last Update Date: 07/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

183 AVE UNIVERSIDAD INTERAMERICA STE 204
SAN GERMAN PR
00683-4459
US

IV. Provider business mailing address

183 AVE UNIVERSIDAD INTERAMERICA STE 204
SAN GERMAN PR
00683-4459
US

V. Phone/Fax

Practice location:
  • Phone: 787-892-8868
  • Fax:
Mailing address:
  • Phone: 787-892-8868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number1879
License Number StatePR

VIII. Authorized Official

Name: MRS. WANDA I MEDINA
Title or Position: PSYCHOLOGIST
Credential:
Phone: 787-892-8868