Provider Demographics
NPI:1508289471
Name:GRACE PSYCHOLOGY CENTER CORPORATION
Entity Type:Organization
Organization Name:GRACE PSYCHOLOGY CENTER CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST/PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMALID
Authorized Official - Middle Name:
Authorized Official - Last Name:ROMAN MARQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:787-435-8816
Mailing Address - Street 1:110 CALLE BORINQUEN
Mailing Address - Street 2:SUITE 2-1
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00976-5981
Mailing Address - Country:US
Mailing Address - Phone:787-435-8816
Mailing Address - Fax:
Practice Address - Street 1:110 CALLE BORINQUEN
Practice Address - Street 2:SUITE 2-1
Practice Address - City:TRUJILLO ALTO
Practice Address - State:PR
Practice Address - Zip Code:00976-5981
Practice Address - Country:US
Practice Address - Phone:787-435-8816
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-29
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5578103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty