Provider Demographics
NPI:1619483906
Name:DIAZ CONDE, MARISELEE
Entity Type:Individual
Prefix:
First Name:MARISELEE
Middle Name:
Last Name:DIAZ CONDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 645 BOX 8167
Mailing Address - Street 2:
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00976-9772
Mailing Address - Country:US
Mailing Address - Phone:787-439-8140
Mailing Address - Fax:
Practice Address - Street 1:1 CALLE MAGNOLIA GARDENS
Practice Address - Street 2:A-28
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00959
Practice Address - Country:US
Practice Address - Phone:787-439-8140
Practice Address - Fax:787-439-8140
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-21
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5790103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty