=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508625849
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CASILLAS PSYCHOLOGICAL SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2024
-----------------------------------------------------
Last Update Date | 10/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 416 AVE PONCE DE LEON STE 1500
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00918-3420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-248-0486
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 718 CALLE CIPRES
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00924-5115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-248-0486
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST
-----------------------------------------------------
Name | GRETCHEN NICOLE CASILLAS CANALES
-----------------------------------------------------
Credential | PSYCHOLOGIST
-----------------------------------------------------
Telephone | 787-248-0486
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------