Healthcare Provider Details

I. General information

NPI: 1831685064
Provider Name (Legal Business Name): IBELIS RODRIGUEZ COSME PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2018
Last Update Date: 03/18/2024
Certification Date: 03/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE ISAAC GONZALEZ MARTINEZ ESQUINA LEDESMA
UTUADO PR
00641
US

IV. Provider business mailing address

URB RIO PIEDRAS HEIGHTS CALLE TIBER 1650 ALTOS
SAN JUAN PR
00926
US

V. Phone/Fax

Practice location:
  • Phone: 787-939-1100
  • Fax:
Mailing address:
  • Phone: 787-515-4955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6562
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: