MEDICARE: CENTRO PSICOSOCIAL TERAPEUTICO DEL SUROESTE INC.

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)		PR

General Provider Information

NPI Number	:	1154773257
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRO PSICOSOCIAL TERAPEUTICO DEL SUROESTE INC.

Provider Business Mailing Address
First Line	:	11 LAS LOMAS #25
Second Line	:
City	:	SAN GERMAN
State	:	PR
Zip	:	00683-3605
Country	:	US
Telephone Number	:	939-264-0606
Fax Number	:

Provider Business Practice Location Address
First Line	:	# 36A CALLE LUIS MUNOZ RIVERA
Second Line	:
City	:	SABANA GRANDE
State	:	PR
Zip	:	00637-1815
Country	:	US
Telephone Number	:	939-264-0606
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL SOCIAL WORKER
Name	:	LORNA B COLON GONZALEZ
Credential	:	MSW
Telephone Number	:	939-264-0606

Provider Enumeration Date	:	07/13/2016
Last Update Date	:	07/13/2016

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