Provider Demographics
NPI:1598905903
Name:ROSADO, IDALIZ (MA)
Entity Type:Individual
Prefix:
First Name:IDALIZ
Middle Name:
Last Name:ROSADO
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 80 BOX 7709
Mailing Address - Street 2:
Mailing Address - City:DORADO
Mailing Address - State:PR
Mailing Address - Zip Code:00646-9552
Mailing Address - Country:US
Mailing Address - Phone:787-616-1901
Mailing Address - Fax:
Practice Address - Street 1:GLENVIEW GARDENS SHOPPING CENTER
Practice Address - Street 2:LOCAL #4
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00730
Practice Address - Country:US
Practice Address - Phone:787-928-7070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-25
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2906103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist