Provider Demographics
NPI:1811253123
Name:FELICIANO LOPEZ, VIDALINA (PHD)
Entity type:Individual
Prefix:MRS
First Name:VIDALINA
Middle Name:
Last Name:FELICIANO LOPEZ
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:AVE. WISTON CHURCHILL COND. VILLAS DEL SENORIAL
Mailing Address - Street 2:APT. 1205
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926
Mailing Address - Country:US
Mailing Address - Phone:787-529-7932
Mailing Address - Fax:
Practice Address - Street 1:AVE. WISTON CHURCHILL COND. VILLAS DEL SENORIAL
Practice Address - Street 2:APT. 1205
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926
Practice Address - Country:US
Practice Address - Phone:787-529-7932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-11
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4111103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical