Provider Demographics
NPI:1588238380
Name:SERRANO, JUAN A (PSYD)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:A
Last Name:SERRANO
Suffix:
Gender:M
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 3 BOX 33819
Mailing Address - Street 2:
Mailing Address - City:AGUADA
Mailing Address - State:PR
Mailing Address - Zip Code:00602-9755
Mailing Address - Country:US
Mailing Address - Phone:787-618-0632
Mailing Address - Fax:
Practice Address - Street 1:2463 E GALA ST STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5210
Practice Address - Country:US
Practice Address - Phone:208-955-7333
Practice Address - Fax:208-955-7330
Is Sole Proprietor?:No
Enumeration Date:2021-05-17
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7637103TC0700X
103TH0100X, 103TP2701X, 390200000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program