Provider Demographics
NPI:1104309079
Name:LACEN, JOSE ANTONIO (PSYD)
Entity type:Individual
Prefix:MR
First Name:JOSE
Middle Name:ANTONIO
Last Name:LACEN
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 40779
Mailing Address - Street 2:MINILLAS STATION
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00940-0779
Mailing Address - Country:US
Mailing Address - Phone:787-306-0309
Mailing Address - Fax:
Practice Address - Street 1:URB PASEO DEL PRADO
Practice Address - Street 2:152 CALLE CAMPESTRE
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00987
Practice Address - Country:US
Practice Address - Phone:787-306-0309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-07
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR006069103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical