=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376848234
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUAN CARLOS CENTENO M.S.PSY.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2011
-----------------------------------------------------
Last Update Date | 01/24/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | AVE. ROOSVELT 601
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00936-8166
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-605-9972
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 601 AVE FD ROOSEVELT
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00918-1137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-605-9972
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 3512
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------