MEDICARE: PSYBLUM PSYCHOLOGICAL SERVICE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist

General Provider Information

NPI Number	:	1124987169
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PSYBLUM PSYCHOLOGICAL SERVICE LLC

Provider Business Mailing Address
First Line	:	AVE LAS AMERICA EDIFICIO PORRATA PILA 209
Second Line	:
City	:	PONCE
State	:	PR
Zip	:	00717
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	AVE LAS AMERICA EDIFICIO PORRATA PILA 209
Second Line	:
City	:	PONCE
State	:	PR
Zip	:	00717
Country	:	US
Telephone Number	:	787-999-9999
Fax Number	:

Authorized Official
Title or Position	:	PROPETARIA
Name	:	ARIELYS ORENGO
Credential	:	PSYD
Telephone Number	:	787-999-9999

Provider Enumeration Date	:	01/16/2026
Last Update Date	:	01/16/2026

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