Provider Demographics
NPI:1700324092
Name:PSICODRAMA PR CP
Entity type:Organization
Organization Name:PSICODRAMA PR CP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VANNESSA
Authorized Official - Middle Name:
Authorized Official - Last Name:PAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:1787-400-5436
Mailing Address - Street 1:7 LAS CASONAS
Mailing Address - Street 2:
Mailing Address - City:AGUADA
Mailing Address - State:PR
Mailing Address - Zip Code:00602-9221
Mailing Address - Country:US
Mailing Address - Phone:787-975-2710
Mailing Address - Fax:
Practice Address - Street 1:CARR 2 KM 156.5
Practice Address - Street 2:510 AVE HOSTOS VISTA VERDE PLAZA SUITE A-12A
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00681
Practice Address - Country:US
Practice Address - Phone:788-975-2710
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-07
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR14054261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)