Provider Demographics
NPI:1235679531
Name:NEGRON MARIN, LISSETTE
Entity Type:Individual
Prefix:
First Name:LISSETTE
Middle Name:
Last Name:NEGRON MARIN
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:EDIF. PORRATA PILA SUITE 208
Mailing Address - Street 2:BLVD. LUIS A FERRE 2431
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00717
Mailing Address - Country:US
Mailing Address - Phone:787-404-1645
Mailing Address - Fax:787-259-5555
Practice Address - Street 1:EDIFICIO PORRATA PILA SUITE 208
Practice Address - Street 2:BLVD. LUIS A FERRE 2431
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717
Practice Address - Country:US
Practice Address - Phone:787-404-1645
Practice Address - Fax:787-259-5555
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-06
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5840103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRIX270AMedicare PIN