Provider Demographics
NPI:1891911780
Name:ORTIZ DE LEON, LISANDRA (PHD)
Entity Type:Individual
Prefix:MISS
First Name:LISANDRA
Middle Name:
Last Name:ORTIZ DE LEON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 43 BOX 11605
Mailing Address - Street 2:
Mailing Address - City:CAYEY
Mailing Address - State:PR
Mailing Address - Zip Code:00736-9221
Mailing Address - Country:US
Mailing Address - Phone:787-205-6527
Mailing Address - Fax:787-263-7536
Practice Address - Street 1:MIGUEL MELENDEZ MUNOZ 9
Practice Address - Street 2:
Practice Address - City:CAYEY
Practice Address - State:PR
Practice Address - Zip Code:00736
Practice Address - Country:US
Practice Address - Phone:787-205-6527
Practice Address - Fax:787-263-7536
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2196103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR2196OtherLICENCIA
PRHV737AMedicare UPIN