Healthcare Provider Details

I. General information

NPI: 1669844338
Provider Name (Legal Business Name): SUI GENERIS CLINICA DE SERVICIOS PSICOLOGICOS P.S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2015
Last Update Date: 10/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 CALLE MUNOZ RIVERA
TOAL ALTA PR
00953
US

IV. Provider business mailing address

47 CALLE MUNOZ RIVERA
TOAL ALTA PR
00953
US

V. Phone/Fax

Practice location:
  • Phone: 939-338-1984
  • Fax:
Mailing address:
  • Phone: 939-338-1984
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3962
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number3001
License Number StatePR
# 3
Primary TaxonomyN
Taxonomy Code364SX0106X
TaxonomyOccupational Health Clinical Nurse Specialist
License Number500
License Number StatePR

VIII. Authorized Official

Name: MISS ANGELA M TABOAS
Title or Position: PRESIDENT
Credential:
Phone: 787-613-1744