Provider Demographics
NPI:1417238353
Name:CAMACHO SANTIAGO, MARISOL (PSYD)
Entity Type:Individual
Prefix:MRS
First Name:MARISOL
Middle Name:
Last Name:CAMACHO SANTIAGO
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:URB. CAMINO DEL SUR 367 CALLE PICAFLOR
Mailing Address - Street 2:
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00731-2814
Mailing Address - Country:US
Mailing Address - Phone:787-309-4749
Mailing Address - Fax:787-840-2317
Practice Address - Street 1:367 CALLE PICAFLOR
Practice Address - Street 2:URB. CAMINO DEL SUR
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716-2814
Practice Address - Country:US
Practice Address - Phone:787-309-4749
Practice Address - Fax:787-840-2317
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-06
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR002163103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical