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General NPI Number Information
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NPI Number | 1407222383
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Entity Type | Organization
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Legal Business Name | CLINICA INTERDISCIPLINARIA DEL SURESTE, INC.
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Dates
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Enumeration Date | 08/14/2015
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Last Update Date | 08/14/2015
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Provider Practice Location Address
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Address Line | 3 AVE. LOS VETERANOS VIILA ROSA B9
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City | GUAYAMA
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State | PR
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Zip | 00728-1399
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Country | US
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Telephone | 787-900-3188
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Fax | 787-866-0984
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Provider Business Mailing Address
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Address Line | PO BOX 1399
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City | PATILLAS
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State | PR
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Zip | 00723-1399
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Country | US
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Telephone | 787-900-3188
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Fax | 787-866-0984
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Authorized Official
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Title or Position | OWNER
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Name | MISS WALESKA S. PABON
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Credential | PSY D
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Telephone | 787-900-3188
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 2020
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License Number State | PR
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