Provider Demographics
NPI:1730766296
Name:PUENTE CARRASCO, NICOLE J
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:J
Last Name:PUENTE CARRASCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:268 CALLE DEL VALLE
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00912-4106
Mailing Address - Country:US
Mailing Address - Phone:787-587-2398
Mailing Address - Fax:
Practice Address - Street 1:CALLE CESAR GONZALEZ 1108
Practice Address - Street 2:
Practice Address - City:RIO PIEDRAS
Practice Address - State:PR
Practice Address - Zip Code:00928
Practice Address - Country:US
Practice Address - Phone:787-758-8019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-29
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6876103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist