MEDICARE: SERVICIOS PSICOLOGICOS RENUEVATE 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	:	1891518189
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SERVICIOS PSICOLOGICOS RENUEVATE LLC

Provider Business Mailing Address
First Line	:	URB. ALTURAS DE SAN BENITO
Second Line	:	CALLE REINA DE LA PAZ 11
City	:	HUMACAO
State	:	PR
Zip	:	00791-9202
Country	:	US
Telephone Number	:	787-645-2587
Fax Number	:

Provider Business Practice Location Address
First Line	:	CARR. 198 KM 22.0
Second Line	:	BO. MONTONES I
City	:	LAS PIEDRAS
State	:	PR
Zip	:	00771-0198
Country	:	US
Telephone Number	:	787-716-0050
Fax Number	:

Authorized Official
Title or Position	:	PSY.D.
Name	:	DR. BERNARDO ROQUE
Credential	:
Telephone Number	:	787-645-2587

Provider Enumeration Date	:	11/05/2024
Last Update Date	:	11/05/2024

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