Provider Demographics
NPI:1093918369
Name:SURILLO, ILEANA C (PSYD)
Entity Type:Individual
Prefix:
First Name:ILEANA
Middle Name:C
Last Name:SURILLO
Suffix:
Gender:F
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:COND.PANORAMA PLAZA
Mailing Address - Street 2:APT. 807
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926
Mailing Address - Country:US
Mailing Address - Phone:787-344-5337
Mailing Address - Fax:
Practice Address - Street 1:AVE. DOMENECH, #400
Practice Address - Street 2:SUITE 507
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918
Practice Address - Country:US
Practice Address - Phone:787-763-6708
Practice Address - Fax:787-765-3650
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1521103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical