Provider Demographics
NPI:1427837954
Name:VICENS-AXTMAYER, VIVIANA BEATRIZ (MA)
Entity type:Individual
Prefix:
First Name:VIVIANA
Middle Name:BEATRIZ
Last Name:VICENS-AXTMAYER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:APT 12 J
Mailing Address - Street 2:1 CALLE HORTENSIA
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-6545
Mailing Address - Country:US
Mailing Address - Phone:787-649-3629
Mailing Address - Fax:
Practice Address - Street 1:CALLE 13 NE
Practice Address - Street 2:#346 ALTOS
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00920
Practice Address - Country:US
Practice Address - Phone:939-625-1356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-25
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6309103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist