Healthcare Provider Details

I. General information

NPI: 1003922865
Provider Name (Legal Business Name): SERVICIOS PSICOLIGICOS RAIGAMBRE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

PLAZA CUPEY GARDENS SECTOR 3
SAN JUAN PR
00936
US

IV. Provider business mailing address

HC 645 BOX 6387
TRUJILLO ALTO PR
00976
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 Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MARILYN RODRIGUEZ
Title or Position: ADMINISTRATOR/CLINICAL PSYCHOLOGIES
Credential: MS
Phone: 787-292-0205