Provider Demographics
NPI:1073937595
Name:BAEZ-SANTOS, IVAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:
Last Name:BAEZ-SANTOS
Suffix:
Gender:M
Credentials:PSYD
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 2318
Mailing Address - Street 2:
Mailing Address - City:SAN GERMAN
Mailing Address - State:PR
Mailing Address - Zip Code:00683-2318
Mailing Address - Country:US
Mailing Address - Phone:787-615-0149
Mailing Address - Fax:
Practice Address - Street 1:CARR. 361, KM. 1.4 INTERIOR
Practice Address - Street 2:
Practice Address - City:SAN GERMAN
Practice Address - State:PR
Practice Address - Zip Code:00683-2318
Practice Address - Country:US
Practice Address - Phone:787-615-0149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-05
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5390103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical