Provider Demographics
NPI:1396058525
Name:CLINICAL & NEUROPSYCHOLOGICAL UNIT OF PR,
Entity type:Organization
Organization Name:CLINICAL & NEUROPSYCHOLOGICAL UNIT OF PR,
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LIZA
Authorized Official - Middle Name:E
Authorized Official - Last Name:SAN MIGUEL
Authorized Official - Suffix:
Authorized Official - Credentials:PSY D
Authorized Official - Phone:787-963-0256
Mailing Address - Street 1:PMB 200 #1353 ST. 19
Mailing Address - Street 2:
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00966
Mailing Address - Country:US
Mailing Address - Phone:787-963-0256
Mailing Address - Fax:787-999-9194
Practice Address - Street 1:CANALS STREET #508
Practice Address - Street 2:UBANIZACION ROOSEVELT , HATO REY
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918
Practice Address - Country:US
Practice Address - Phone:787-963-0256
Practice Address - Fax:787-999-9194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-16
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6040261Q00000X
PR2598103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NPIMedicare UPIN