Provider Demographics
NPI:1861099947
Name:VIVES DE LEON, ANTHONY (PSYD)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:
Last Name:VIVES DE LEON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 71325
Mailing Address - Street 2:PMB 299
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00936
Mailing Address - Country:US
Mailing Address - Phone:787-934-1964
Mailing Address - Fax:
Practice Address - Street 1:ITURREGUI PLAZA SHOPPING CENTER,
Practice Address - Street 2:1135 AVENIDA 65 DE INFANTERIA, STE 215-A
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00924
Practice Address - Country:US
Practice Address - Phone:939-246-9126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-02
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6310103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical