Provider Demographics
NPI:1144427162
Name:LICHA BAQUERO, MIGUEL A (PHD)
Entity Type:Individual
Prefix:DR
First Name:MIGUEL
Middle Name:A
Last Name:LICHA BAQUERO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:130 AVE WINSTON CHURCHILL
Mailing Address - Street 2:PMB 128
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-6013
Mailing Address - Country:US
Mailing Address - Phone:787-781-5061
Mailing Address - Fax:787-781-5092
Practice Address - Street 1:100 CARR 165
Practice Address - Street 2:CENTRO INTERNACIONAL DE MERCADEO,TORRE I, SUITE 401
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00968-8047
Practice Address - Country:US
Practice Address - Phone:787-781-5061
Practice Address - Fax:787-781-5092
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PR1199103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist