Provider Demographics
NPI:1003204579
Name:IRIZARRY, TAYLISS
Entity Type:Individual
Prefix:
First Name:TAYLISS
Middle Name:
Last Name:IRIZARRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 ONIX
Mailing Address - Street 2:URBANIZACION PEDREGAL
Mailing Address - City:SAN GERMAN
Mailing Address - State:PR
Mailing Address - Zip Code:00683-2529
Mailing Address - Country:US
Mailing Address - Phone:787-210-4679
Mailing Address - Fax:
Practice Address - Street 1:74 ONIX
Practice Address - Street 2:URB. PEDREGAL
Practice Address - City:SAN GERMAN
Practice Address - State:PR
Practice Address - Zip Code:00683-2529
Practice Address - Country:US
Practice Address - Phone:787-210-4679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-06
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3571103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist