1659077295 NPI number — PSYCHOLOGICAL WELLNESS CENTER LLC

Table of content: (NPI 1659077295)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659077295 NPI number — PSYCHOLOGICAL WELLNESS CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PSYCHOLOGICAL WELLNESS CENTER LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659077295
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3372
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GUAYAMA
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00785-3372
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-246-2728
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CARR.PR-54 INT. RAMAL 7711
Provider Second Line Business Practice Location Address:
BO. POZO HONDO
Provider Business Practice Location Address City Name:
GUAYAMA
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00784
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-246-2827
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/06/2023

Additional Information

Authorized Official

Authorized Official Last Name:
HERNANDEZ FERNANDEZ
Authorized Official First Name:
MARIELLY
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINICAL PSYCHOLOGY
Authorized Official Telephone Number:
787-246-2827

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4519251 . This is a "DRIVER LICENSE" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".




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