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General NPI Number Information
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NPI Number | 1528330362
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Entity Type | Organization
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Legal Business Name | PSICSUR
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Dates
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Enumeration Date | 02/08/2012
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Last Update Date | 02/08/2012
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Provider Practice Location Address
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Address Line | 9140 CALLE MARINA SUITE 502
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City | PONCE
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State | PR
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Zip | 00717
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Country | US
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Telephone | 787-485-6348
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Fax |
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Provider Business Mailing Address
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Address Line | 9140 CALLE MARINA SUITE 502
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City | PONCE
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State | PR
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Zip | 00717
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Country | US
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Telephone | 787-485-6348
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Fax |
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Authorized Official
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Title or Position | COORDINADOR GENERAL
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Name | DR. JOSE ANGEL GANDIA
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Credential | PH.D. CLINICAL PSY.
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Telephone | 787-485-6348
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number | 3500
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License Number State | PR
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