Provider Demographics
NPI:1497389290
Name:BURGOS GOMEZ, ILEANA K (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ILEANA
Middle Name:K
Last Name:BURGOS GOMEZ
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:HC 2 BOX 6159
Mailing Address - Street 2:
Mailing Address - City:BAJADERO
Mailing Address - State:PR
Mailing Address - Zip Code:00616-9761
Mailing Address - Country:US
Mailing Address - Phone:787-983-9161
Mailing Address - Fax:
Practice Address - Street 1:METRO MEDICAL CENTER
Practice Address - Street 2:SUITE A 801 TORRE A 995 PR-2
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00959
Practice Address - Country:US
Practice Address - Phone:787-672-5384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-02
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6463103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR824Medicaid