Provider Demographics
NPI:1174023535
Name:BLVD PSYCHOLOGICAL SERVICES P.S.C.
Entity Type:Organization
Organization Name:BLVD PSYCHOLOGICAL SERVICES P.S.C.
Other - Org Name:CLINIC/CENTER - MULTI-SPECIALTY
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENTA/DIRECTORA
Authorized Official - Prefix:
Authorized Official - First Name:BRENDALY
Authorized Official - Middle Name:
Authorized Official - Last Name:GARCIA MORALES
Authorized Official - Suffix:
Authorized Official - Credentials:PSY D
Authorized Official - Phone:787-462-1730
Mailing Address - Street 1:3326 PASEO CARMEN
Mailing Address - Street 2:
Mailing Address - City:TOA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00949-3136
Mailing Address - Country:US
Mailing Address - Phone:939-399-3371
Mailing Address - Fax:939-399-3372
Practice Address - Street 1:3326 PASEO CARMEN
Practice Address - Street 2:
Practice Address - City:TOA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00949-3136
Practice Address - Country:US
Practice Address - Phone:939-399-3371
Practice Address - Fax:939-399-3372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-12
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR101YP2500X, 103TC2200X, 103TH0004X
103TA0700X, 103TC0700X, 208D00000X, 261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & AgingGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealthGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR5672OtherLICENSE NUMBER