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General NPI Number Information
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NPI Number | 1760753701
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Entity Type | Organization
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Legal Business Name | GENESIS INSTITUTO DE SERVICIOS MULTIDISCIPLINARIOS, INC.
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Dates
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Enumeration Date | 01/23/2012
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Last Update Date | 01/23/2012
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Provider Practice Location Address
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Address Line | C1A CALLE 4 SUITE 7
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City | CAGUAS
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State | PR
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Zip | 00725-4613
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Country | US
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Telephone | 787-374-3230
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Fax |
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Provider Business Mailing Address
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Address Line | C1 A4 CONDADO MODERNO SUITE 7
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City | CAGUAS
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State | PUERTO RICO
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Zip | 00725
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Country | UM
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PSYCHOLOGIST
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Name | DR. CARMEN IVELISSE MEDINA
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Credential |
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Telephone | 787-374-3230
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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 | 1914
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License Number State | PR
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