Provider Demographics
NPI:1528554755
Name:ESTRADA RODRIGUEZ, JOHANA M (PSYD)
Entity type:Individual
Prefix:MRS
First Name:JOHANA
Middle Name:M
Last Name:ESTRADA RODRIGUEZ
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB VALLE ARRIBA HEIGHTS
Mailing Address - Street 2:O16 CALLE EUCALIPTO
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00983
Mailing Address - Country:US
Mailing Address - Phone:787-688-6031
Mailing Address - Fax:
Practice Address - Street 1:CALLE RVDO. DOMINGO MARRERO NAVARRO
Practice Address - Street 2:EDIFICIO #5, 3ER PISO
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00925
Practice Address - Country:US
Practice Address - Phone:787-688-6031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6209103TC0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR6209OtherLICENSURE PSYCHOLOGIST
PRLG427Medicaid