Provider Demographics
NPI:1164754826
Name:PEREZ RODRIGUEZ, MARIO LUIS (PSYCHOLOGIST)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:LUIS
Last Name:PEREZ RODRIGUEZ
Suffix:
Gender:M
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB.VEREDAS
Mailing Address - Street 2:#389
Mailing Address - City:GURABO
Mailing Address - State:PR
Mailing Address - Zip Code:00778
Mailing Address - Country:US
Mailing Address - Phone:787-453-6132
Mailing Address - Fax:
Practice Address - Street 1:MED WELLNESS CLINIC
Practice Address - Street 2:PD PLAZA LOCAL 3
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725
Practice Address - Country:US
Practice Address - Phone:787-453-6132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-05
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3627103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR3627OtherLISENCE