Provider Demographics
NPI:1295433977
Name:CEPEDA FAX, SUILARIAM (PHD)
Entity type:Individual
Prefix:DR
First Name:SUILARIAM
Middle Name:
Last Name:CEPEDA FAX
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 1:30 CALLE HORTENCIA
Mailing Address - Street 2:
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00987-2203
Mailing Address - Country:US
Mailing Address - Phone:787-387-6603
Mailing Address - Fax:
Practice Address - Street 1:30 CALLE HORTENCIA
Practice Address - Street 2:
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00987-2203
Practice Address - Country:US
Practice Address - Phone:787-387-6603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-21
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6751103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR6751Medicaid