=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053757575
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PSY-Q GROUP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2013
-----------------------------------------------------
Last Update Date | 05/13/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | AVE. REGIMIENTO # 295 DE INFANTERIA ESQ. RICKY SEDA VALLE TOLIMA
-----------------------------------------------------
City | CAGUAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-669-1150
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 536
-----------------------------------------------------
City | CAGUAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00726-0536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-669-1150
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER & PRESIDENT
-----------------------------------------------------
Name | JENNIFER CASTRO
-----------------------------------------------------
Credential | PSYCHOLOGIST
-----------------------------------------------------
Telephone | 787-669-1150
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 3089
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------