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General NPI Number Information
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NPI Number | 1508115700
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Entity Type | Individual
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Provider Name | LYZETTE DINORAH COSTA
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Gender | Female
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Dates
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Enumeration Date | 09/04/2012
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Last Update Date | 09/04/2012
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Provider Practice Location Address
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Address Line | URB. HUYKE 204 CALLE UNION
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City | SAN JUAN
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State | PR
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Zip | 00918
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Country | US
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Telephone | 787-772-4783
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Fax |
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Provider Business Mailing Address
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Address Line | 1407 AVE. ASHFORD COND. CONDADO AMBASSADOR APT. 603
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City | SAN JUAN
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State | PR
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Zip | 00907
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Country | US
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Telephone | 787-560-5696
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 3995
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License Number State | PR
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