Healthcare Provider Details

I. General information

NPI: 1306644604
Provider Name (Legal Business Name): SOULCERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2025
Last Update Date: 03/04/2025
Certification Date: 03/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

URB. VALPARAISO J29 CALLE 4
TOA BAJA PR
00949-4022
US

IV. Provider business mailing address

URB. VALPARAISO J29 CALLE 4
TOA BAJA PR
00949
US

V. Phone/Fax

Practice location:
  • Phone: 939-202-9296
  • Fax:
Mailing address:
  • Phone: 939-202-9296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. MILLICENT MALDONADO
Title or Position: CHIEF PSYCHOLOGIST
Credential: PSYD
Phone: 939-202-9296