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General NPI Number Information
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NPI Number | 1023579844
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Entity Type | Individual
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Provider Name | SULY DAIRAY ILLAS MENDEZ PHD
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Gender | Female
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Dates
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Enumeration Date | 03/26/2019
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Last Update Date | 01/03/2020
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Provider Practice Location Address
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Address Line | CARR 125 KM 12.6 BO CAPA VARGAS
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City | MOCA
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State | PR
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Zip | 00676-0067
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Country | US
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Telephone | 787-642-0559
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Fax |
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Provider Business Mailing Address
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Address Line | HC 2 BOX 12446
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City | MOCA
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State | PR
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Zip | 00676-8263
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Country | US
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Telephone | 787-642-0559
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number | 3569
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License Number State | PR
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