Basic Information
| Provider Information | |||||||||
| NPI: | 1609129683 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | YPERVASI CSP | ||||||||
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| Mailing Information | |||||||||
| Address1: | LOMAS DE CAROLINA D32 | ||||||||
| Address2: | CALLE MONTE MEMBRILLO | ||||||||
| City: | CAROLINA | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009870000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7876465397 | ||||||||
| FaxNumber: | 7872762923 | ||||||||
| Practice Location | |||||||||
| Address1: | CARR 857 KM0.4 BO CANOVANILLAS | ||||||||
| Address2: | |||||||||
| City: | CAROLINA | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009870000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877763840 | ||||||||
| FaxNumber: | 7872762923 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2012 | ||||||||
| LastUpdateDate: | 10/16/2012 | ||||||||
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| AuthorizedOfficialLastName: | BARRETO CORREA | ||||||||
| AuthorizedOfficialFirstName: | FRANCHESKA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7876465397 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PSYD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 3080 | PR | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 3080 | 01 | PR | LIC | OTHER |