Provider Demographics
NPI:1851500904
Name:ROSA, MAYRA R (PSYD)
Entity type:Individual
Prefix:DR
First Name:MAYRA
Middle Name:R
Last Name:ROSA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:MAYRA
Other - Middle Name:R
Other - Last Name:ROSA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:PMB 1179, PO BOX 6400
Mailing Address - Street 2:
Mailing Address - City:CAYEY
Mailing Address - State:PR
Mailing Address - Zip Code:00737
Mailing Address - Country:US
Mailing Address - Phone:787-263-6150
Mailing Address - Fax:
Practice Address - Street 1:CONDADO MODERNO
Practice Address - Street 2:13 ST M31
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725
Practice Address - Country:US
Practice Address - Phone:787-448-2145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2596103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical