Provider Demographics
NPI:1093220519
Name:RIVERA MEDINA, CARMEN LYDIA
Entity Type:Individual
Prefix:DR
First Name:CARMEN
Middle Name:LYDIA
Last Name:RIVERA MEDINA
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:CHALETS DEL PARQUE
Mailing Address - Street 2:12 AVE ARBOLOTE #144
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00969-5507
Mailing Address - Country:US
Mailing Address - Phone:939-248-7323
Mailing Address - Fax:
Practice Address - Street 1:CALLE 2 E-11, SANTA CRUZ
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961-3516
Practice Address - Country:US
Practice Address - Phone:939-248-7323
Practice Address - Fax:888-251-9661
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-06
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2210103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical