=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356086482
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAILENE MARIE ROMAN TEJERA PSYD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2022
-----------------------------------------------------
Last Update Date | 07/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CARR 119 KM 5.5 INTERIOR, BO. PUENTE
-----------------------------------------------------
City | CAMUY
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00627-0062
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-644-0743
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 162 CALLE HELIO
-----------------------------------------------------
City | ARECIBO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00612-8866
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-644-0743
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 7260
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------