Provider Demographics
NPI:1801942958
Name:MEDINA PEREZ, CARMEN I (PHD)
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:I
Last Name:MEDINA PEREZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:STREET 1 A 4 CONDADO MODERNO
Mailing Address - Street 2:SUITE 6
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00725
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:STREET 1 A 4 CONDADO MODERNO
Practice Address - Street 2:SUITE 6
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725
Practice Address - Country:US
Practice Address - Phone:787-374-3230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1914103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent