Provider Demographics
NPI:1265007298
Name:PENA DIAZ, CORALYS (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CORALYS
Middle Name:
Last Name:PENA DIAZ
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 320
Mailing Address - Street 2:
Mailing Address - City:COMERIO
Mailing Address - State:PR
Mailing Address - Zip Code:00782-0320
Mailing Address - Country:US
Mailing Address - Phone:787-483-3504
Mailing Address - Fax:
Practice Address - Street 1:CARR 779 KM 10.1 BO CEDRO ARRIBA SECTOR EL ABANICO
Practice Address - Street 2:
Practice Address - City:NARANJITO
Practice Address - State:PR
Practice Address - Zip Code:00719
Practice Address - Country:US
Practice Address - Phone:787-236-2929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-21
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6863103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR6863OtherPSYCHOLOGIST LICENSE