Healthcare Provider Details

I. General information

NPI: 1245245091
Provider Name (Legal Business Name): SERVICIOS PSICOLOGICOS RAIGAMBRE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PLAZA CUPEY GARDENS SECTOR 3 URB CUPEY GARDENS
SAN JUAN PR
00936
US

IV. Provider business mailing address

HC 645 BOX 6387
TRUJILLO ALTO PR
00976-9746
US

V. Phone/Fax

Practice location:
  • Phone: 787-292-0205
  • Fax: 787-292-0205
Mailing address:
  • Phone: 787-292-0205
  • Fax: 787-292-0205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1330
License Number StatePR

VIII. Authorized Official

Name: MARILYN RODRIGUEZ
Title or Position: ADMINISTRATOR
Credential: M.S.
Phone: 787-292-0205