Provider Demographics
NPI:1043644867
Name:PEDRAZA, MARIOLA
Entity Type:Individual
Prefix:
First Name:MARIOLA
Middle Name:
Last Name:PEDRAZA
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 1:15 CALLE BARCELO
Mailing Address - Street 2:
Mailing Address - City:BARRANQUITAS
Mailing Address - State:PR
Mailing Address - Zip Code:00794-1710
Mailing Address - Country:US
Mailing Address - Phone:787-617-9583
Mailing Address - Fax:
Practice Address - Street 1:15 CALLE BARCELO
Practice Address - Street 2:
Practice Address - City:BARRANQUITAS
Practice Address - State:PR
Practice Address - Zip Code:00794-1710
Practice Address - Country:US
Practice Address - Phone:787-617-9583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-28
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4308103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical