MEDICARE: CENTRO INTERDISCIPLINARIO PSICOTERAPEUTICO PSC

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	2562	PR

General Provider Information

NPI Number	:	1871723882
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRO INTERDISCIPLINARIO PSICOTERAPEUTICO PSC

Provider Business Mailing Address
First Line	:	102 CALLE 1 URBANIZACION JACAGUAX
Second Line	:
City	:	JUANA DIAZ
State	:	PR
Zip	:	00795-2532
Country	:	US
Telephone Number	:	787-837-6194
Fax Number	:	787-837-6194

Provider Business Practice Location Address
First Line	:	13 CALLE DE LA CRUZ
Second Line	:
City	:	JUANA DIAZ
State	:	PR
Zip	:	00795-2426
Country	:	US
Telephone Number	:	787-636-6661
Fax Number	:	787-837-6194

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RITA M MERCADO
Credential	:	PSY D
Telephone Number	:	787-602-2063

Provider Enumeration Date	:	07/24/2009
Last Update Date	:	10/03/2011

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