Provider Demographics
NPI:1194463372
Name:IBAN-CORDERO, CESAR LEONEL
Entity Type:Individual
Prefix:
First Name:CESAR
Middle Name:LEONEL
Last Name:IBAN-CORDERO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB. MONTE BRISAS
Mailing Address - Street 2:ST. F-J16
Mailing Address - City:FAJARDO
Mailing Address - State:PR
Mailing Address - Zip Code:00738
Mailing Address - Country:US
Mailing Address - Phone:787-206-0150
Mailing Address - Fax:
Practice Address - Street 1:AVE. PRINCIPAL BARALT
Practice Address - Street 2:G-24
Practice Address - City:FAJARDO
Practice Address - State:PR
Practice Address - Zip Code:00738
Practice Address - Country:US
Practice Address - Phone:787-863-7008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-26
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6798103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical