Provider Demographics
NPI:1396191581
Name:RIVERA BLANCO, IDALIS (MASTER DEGREE)
Entity Type:Individual
Prefix:MRS
First Name:IDALIS
Middle Name:
Last Name:RIVERA BLANCO
Suffix:
Gender:F
Credentials:MASTER DEGREE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 2 BOX 4750
Mailing Address - Street 2:
Mailing Address - City:COAMO
Mailing Address - State:PR
Mailing Address - Zip Code:00769-9575
Mailing Address - Country:US
Mailing Address - Phone:787-392-7673
Mailing Address - Fax:
Practice Address - Street 1:HC 2 BOX 4750
Practice Address - Street 2:
Practice Address - City:COAMO
Practice Address - State:PR
Practice Address - Zip Code:00769-9575
Practice Address - Country:US
Practice Address - Phone:787-392-7673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-06
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2790103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist