Provider Demographics
NPI:1104402007
Name:MEDINA RIVERA, GERARDO MANUEL (PHD)
Entity type:Individual
Prefix:DR
First Name:GERARDO
Middle Name:MANUEL
Last Name:MEDINA RIVERA
Suffix:
Gender:M
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:PO BOX 1268
Mailing Address - Street 2:
Mailing Address - City:YAUCO
Mailing Address - State:PR
Mailing Address - Zip Code:00698-1268
Mailing Address - Country:US
Mailing Address - Phone:787-913-1555
Mailing Address - Fax:
Practice Address - Street 1:URB. JARDINES DE BORINQUEN A-1
Practice Address - Street 2:SUITE 2
Practice Address - City:YAUCO
Practice Address - State:PR
Practice Address - Zip Code:00698-0069
Practice Address - Country:US
Practice Address - Phone:787-913-1555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-22
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6831103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical