Provider Demographics
NPI:1235261579
Name:CALDERON-VIGO, KETSIE IVELISSE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KETSIE
Middle Name:IVELISSE
Last Name:CALDERON-VIGO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2M40 CALLE HORTENSIA
Mailing Address - Street 2:LOMAS VERDES
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00956-3419
Mailing Address - Country:US
Mailing Address - Phone:787-466-7747
Mailing Address - Fax:787-720-5091
Practice Address - Street 1:H13 VILLA DEL CARMEN
Practice Address - Street 2:AVENIDA LUIS MUNOZ MARIN
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725
Practice Address - Country:US
Practice Address - Phone:787-466-7747
Practice Address - Fax:787-720-5091
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2731103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical