Provider Demographics
NPI:1164945705
Name:MERCADO, NICHOLE ANDREE (LCDA)
Entity Type:Individual
Prefix:MRS
First Name:NICHOLE
Middle Name:ANDREE
Last Name:MERCADO
Suffix:
Gender:F
Credentials:LCDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CALLE MIRTOS
Mailing Address - Street 2:URB EL VALLE
Mailing Address - City:LAJAS
Mailing Address - State:PR
Mailing Address - Zip Code:00667
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:XII CALLE ALFONSO
Practice Address - Street 2:ESQUINA AVENIDA UNIVERSIDAD INTERAMERICANA
Practice Address - City:SAN GERMAN
Practice Address - State:PR
Practice Address - Zip Code:00683
Practice Address - Country:US
Practice Address - Phone:787-892-9911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-25
Last Update Date:2017-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5830103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR5830OtherSELF