Provider Demographics
NPI:1609415272
Name:MEDINA AGOSTO, EDWIN JOEL (PSYCHOLOGIST)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:JOEL
Last Name:MEDINA AGOSTO
Suffix:
Gender:M
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 VILLA ENCANTADA
Mailing Address - Street 2:
Mailing Address - City:CIDRA
Mailing Address - State:PR
Mailing Address - Zip Code:00739-9563
Mailing Address - Country:US
Mailing Address - Phone:787-212-9941
Mailing Address - Fax:
Practice Address - Street 1:29 VILLA ENCANTADA
Practice Address - Street 2:
Practice Address - City:CIDRA
Practice Address - State:PR
Practice Address - Zip Code:00739-9563
Practice Address - Country:US
Practice Address - Phone:787-212-9941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-31
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6508103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling