Provider Demographics
NPI:1083373971
Name:PADILLA, IVELISSE (PSY,D)
Entity Type:Individual
Prefix:DR
First Name:IVELISSE
Middle Name:
Last Name:PADILLA
Suffix:
Gender:F
Credentials:PSY,D
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 360533
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00936-0533
Mailing Address - Country:US
Mailing Address - Phone:787-454-5949
Mailing Address - Fax:
Practice Address - Street 1:METRO MEDICAL CENTER
Practice Address - Street 2:SUITE A801 TORRE A, 995 PR-2
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00959
Practice Address - Country:US
Practice Address - Phone:787-454-5949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7223103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty