MEDICARE: PSYCH WELLNESS CENTER 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	3348	PR

General Provider Information

NPI Number	:	1942502968
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PSYCH WELLNESS CENTER PSC

Provider Business Mailing Address
First Line	:	453 CALLE CESAR GONZALEZ
Second Line	:	OFICINA 6
City	:	SAN JUAN
State	:	PR
Zip	:	00918-2638
Country	:	US
Telephone Number	:	787-392-9990
Fax Number	:

Provider Business Practice Location Address
First Line	:	453 CALLE CESAR GONZALEZ
Second Line	:	OFICINA 6
City	:	SAN JUAN
State	:	PR
Zip	:	00918-2638
Country	:	US
Telephone Number	:	787-392-9990
Fax Number	:

Authorized Official
Title or Position	:	PSYCHOLOGY/PRESIDENT
Name	:	DR. AMELIA RODRIGUEZ ACEVEDO
Credential	:	PHD
Telephone Number	:	787-392-9990

Provider Enumeration Date	:	11/23/2010
Last Update Date	:	11/23/2010

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