Provider Demographics
NPI:1528330362
Name:PSICSUR
Entity type:Organization
Organization Name:PSICSUR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COORDINADOR GENERAL
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:ANGEL
Authorized Official - Last Name:GANDIA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD CLINICAL PSY
Authorized Official - Phone:787-485-6348
Mailing Address - Street 1:9140 CALLE MARINA
Mailing Address - Street 2:SUITE 502
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00717
Mailing Address - Country:US
Mailing Address - Phone:787-485-6348
Mailing Address - Fax:
Practice Address - Street 1:9140 CALLE MARINA
Practice Address - Street 2:SUITE 502
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717
Practice Address - Country:US
Practice Address - Phone:787-485-6348
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3500261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)