Provider Demographics
NPI:1669844338
Name:SUI GENERIS CLINICA DE SERVICIOS PSICOLOGICOS P.S.C.
Entity Type:Organization
Organization Name:SUI GENERIS CLINICA DE SERVICIOS PSICOLOGICOS P.S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:M
Authorized Official - Last Name:TABOAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-613-1744
Mailing Address - Street 1:47 CALLE MUNOZ RIVERA
Mailing Address - Street 2:
Mailing Address - City:TOAL ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00953
Mailing Address - Country:US
Mailing Address - Phone:939-338-1984
Mailing Address - Fax:
Practice Address - Street 1:47 CALLE MUNOZ RIVERA
Practice Address - Street 2:
Practice Address - City:TOAL ALTA
Practice Address - State:PR
Practice Address - Zip Code:00953
Practice Address - Country:US
Practice Address - Phone:939-338-1984
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-21
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3962103T00000X
PR3001235Z00000X
PR500364SX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No364SX0106XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistOccupational HealthGroup - Multi-Specialty