Provider Demographics
NPI:1235848060
Name:CARRILLO NIEVES, STEPHANIE ODALYS (PSYD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ODALYS
Last Name:CARRILLO NIEVES
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:STEPHANIE
Other - Middle Name:ODALYS
Other - Last Name:CARRILLO NIEVES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:URB. LOS PINOS I
Mailing Address - Street 2:CALLE PINO MARITIMO #306
Mailing Address - City:ARECIBO
Mailing Address - State:PR
Mailing Address - Zip Code:00612
Mailing Address - Country:US
Mailing Address - Phone:787-562-5757
Mailing Address - Fax:
Practice Address - Street 1:EDIFICIO ARECIBO MEDICAL PLAZA
Practice Address - Street 2:AVE. JOSE CELSO BARBOSA #65, SUITE 103
Practice Address - City:ARECIBO
Practice Address - State:PR
Practice Address - Zip Code:00612-0061
Practice Address - Country:US
Practice Address - Phone:787-562-5757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-21
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6749103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical