Provider Demographics
NPI:1003188244
Name:EOS: PSYCHOLOGICAL WELLNESS CENTRE
Entity Type:Organization
Organization Name:EOS: PSYCHOLOGICAL WELLNESS CENTRE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:AGNES
Authorized Official - Middle Name:SYBEL
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:787-550-9708
Mailing Address - Street 1:CALLE 31 AF 24 URB. INTERAMERICANA
Mailing Address - Street 2:
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00976
Mailing Address - Country:US
Mailing Address - Phone:787-550-9708
Mailing Address - Fax:
Practice Address - Street 1:AVE MONSERRATE AB 18 LOCAL 4
Practice Address - Street 2:VALLE ARRIBA HEIGHTS
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00985
Practice Address - Country:US
Practice Address - Phone:787-550-9708
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-03
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4105261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)