=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063390029
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PSICO GROUP DE PR INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2025
-----------------------------------------------------
Last Update Date | 08/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CONCORDIA SHOPPING CENTER AVE. 65TH INFANTERIA BO. SABANA LLANA SUR
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00729-0604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-220-1272
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 604
-----------------------------------------------------
City | CANOVANAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00729-0604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-220-1272
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSICOLOGY
-----------------------------------------------------
Name | ANDRES R ANDINO SERRANO
-----------------------------------------------------
Credential | M.PSY
-----------------------------------------------------
Telephone | 787-220-1272
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------