Provider Demographics
NPI:1407222383
Name:CLINICA INTERDISCIPLINARIA DEL SURESTE, INC.
Entity Type:Organization
Organization Name:CLINICA INTERDISCIPLINARIA DEL SURESTE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:WALESKA
Authorized Official - Middle Name:S
Authorized Official - Last Name:PABON
Authorized Official - Suffix:
Authorized Official - Credentials:PSY D
Authorized Official - Phone:787-900-3188
Mailing Address - Street 1:PO BOX 1399
Mailing Address - Street 2:
Mailing Address - City:PATILLAS
Mailing Address - State:PR
Mailing Address - Zip Code:00723-1399
Mailing Address - Country:US
Mailing Address - Phone:787-900-3188
Mailing Address - Fax:787-866-0984
Practice Address - Street 1:3 AVE. LOS VETERANOS
Practice Address - Street 2:VIILA ROSA B9
Practice Address - City:GUAYAMA
Practice Address - State:PR
Practice Address - Zip Code:00728-1399
Practice Address - Country:US
Practice Address - Phone:787-900-3188
Practice Address - Fax:787-866-0984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-14
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2020103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty