Provider Demographics
NPI:1073912416
Name:COLON MARCANO, EDGAR LUIS (PHD)
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:LUIS
Last Name:COLON MARCANO
Suffix:
Gender:M
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:PO BOX 579
Mailing Address - Street 2:
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00986-0579
Mailing Address - Country:US
Mailing Address - Phone:787-371-2655
Mailing Address - Fax:
Practice Address - Street 1:1007 AVE MUNOZ RIVERA
Practice Address - Street 2:COND. DARLINGTON SUITE 202
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00925-2717
Practice Address - Country:US
Practice Address - Phone:787-688-8756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5411103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical