Healthcare Provider Details

I. General information

NPI: 1952113102
Provider Name (Legal Business Name): CERTIFIED COMMUNITY BEHAVIORAL HEALTH CLINIC (CCBHC)
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2025
Last Update Date: 12/22/2025
Certification Date: 12/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR PR 122 KM 0.6 AVE CASTRO PEREZ BO. GUAMA
SAN GERMAN PR
00683
US

IV. Provider business mailing address

PO BOX 190
MAYAGUEZ PR
00681-0190
US

V. Phone/Fax

Practice location:
  • Phone: 787-652-2376
  • Fax:
Mailing address:
  • Phone: 787-831-5800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TANIA RODRIGUEZ
Title or Position: CEO
Credential:
Phone: 787-831-5800