Basic Information
Provider Information | |||||||||
NPI: | 1720360142 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UNIVERSIDAD CENTRAL DEL CARIBE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 60327 | ||||||||
Address2: |   | ||||||||
City: | BAYAMON | ||||||||
State: | PR | ||||||||
PostalCode: | 009606032 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | AVENIDA LAUREL ESQUINA SANTA JUANITA | ||||||||
Address2: | #100 | ||||||||
City: | BAYAMON | ||||||||
State: | PR | ||||||||
PostalCode: | 009606032 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7877983001 | ||||||||
FaxNumber: | 7877780460 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/12/2011 | ||||||||
LastUpdateDate: | 09/12/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RODRIGUEZ-IRIZARRY | ||||||||
AuthorizedOfficialFirstName: | JOSE | ||||||||
AuthorizedOfficialMiddleName: | G | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT UCC | ||||||||
AuthorizedOfficialTelephone: | 7877983001 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |   |
No ID Information.