Provider Demographics
NPI:1205228459
Name:BERRIOS-SANTIAGO, NICKOLE J
Entity Type:Individual
Prefix:MRS
First Name:NICKOLE
Middle Name:J
Last Name:BERRIOS-SANTIAGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 CALLE AMAPA
Mailing Address - Street 2:URB. VISTA ALEGRE
Mailing Address - City:VILLALBA
Mailing Address - State:PR
Mailing Address - Zip Code:00766-2905
Mailing Address - Country:US
Mailing Address - Phone:787-517-1136
Mailing Address - Fax:
Practice Address - Street 1:506 COTO LAUREL, CARR. MARGINAL
Practice Address - Street 2:LEGACY OFFICE PARK SUITE 102
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00780-9998
Practice Address - Country:US
Practice Address - Phone:787-813-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-25
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4076103TS0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool