Provider Demographics
NPI:1972716819
Name:LAUREANO, ILIA IVETTE (PSY)
Entity type:Individual
Prefix:MRS
First Name:ILIA
Middle Name:IVETTE
Last Name:LAUREANO
Suffix:
Gender:F
Credentials:PSY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:734 CALLE CIBUCO
Mailing Address - Street 2:
Mailing Address - City:TOA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00953-5114
Mailing Address - Country:US
Mailing Address - Phone:787-462-4825
Mailing Address - Fax:
Practice Address - Street 1:734 CALLE CIBUCO
Practice Address - Street 2:
Practice Address - City:TOA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00953-5114
Practice Address - Country:US
Practice Address - Phone:787-462-4825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR592103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical