Provider Demographics
NPI:1023579844
Name:ILLAS MENDEZ, SULY DAIRAY (PHD)
Entity Type:Individual
Prefix:DR
First Name:SULY
Middle Name:DAIRAY
Last Name:ILLAS MENDEZ
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:HC 2 BOX 12446
Mailing Address - Street 2:
Mailing Address - City:MOCA
Mailing Address - State:PR
Mailing Address - Zip Code:00676-8263
Mailing Address - Country:US
Mailing Address - Phone:787-642-0559
Mailing Address - Fax:
Practice Address - Street 1:CARR 125 KM 12.6 BO CAPA VARGAS
Practice Address - Street 2:
Practice Address - City:MOCA
Practice Address - State:PR
Practice Address - Zip Code:00676-0067
Practice Address - Country:US
Practice Address - Phone:787-642-0559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-26
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3569103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling