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General NPI Number Information
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NPI Number | 1396763561
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Entity Type | Organization
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Legal Business Name | CENTRO INTERDISCIPLINARIO DE SALUD MENTAL, C.S.P
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Dates
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Enumeration Date | 07/17/2006
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Last Update Date | 05/15/2014
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Provider Practice Location Address
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Address Line | CENTRO CARIBE BUILDING 2053 PONCE BY PASS SUITE 205
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City | PONCE
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State | PR
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Zip | 00717-1308
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Country | US
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Telephone | 787-453-8666
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Fax | 787-841-4170
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Provider Business Mailing Address
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Address Line | PO BOX 632
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City | MERCEDITA
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State | PR
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Zip | 00715-0632
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Country | US
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Telephone | 787-453-8666
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Fax | 787-841-4170
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Authorized Official
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Title or Position | PRESIDENT
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Name | CARLOS A LADO-CORNEJO
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Credential | MD
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Telephone | 787-453-8666
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 12657
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License Number State | PR
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 2334
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License Number State | PR
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