Provider Demographics
NPI:1508840224
Name:GARCIA, MIRELLY (PSYD)
Entity Type:Individual
Prefix:MISS
First Name:MIRELLY
Middle Name:
Last Name:GARCIA
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:COND MONTEBELLO
Mailing Address - Street 2:APT. G-313
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00976-4943
Mailing Address - Country:US
Mailing Address - Phone:787-502-3630
Mailing Address - Fax:
Practice Address - Street 1:AVE PONCE DE LEON
Practice Address - Street 2:# 728
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918-1000
Practice Address - Country:US
Practice Address - Phone:787-754-9720
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2248103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR68174Medicare ID - Type Unspecified