Provider Demographics
NPI:1912372889
Name:PSICOLOGIA AVANZADA LLC
Entity Type:Organization
Organization Name:PSICOLOGIA AVANZADA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENTE
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:RIVERA GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PSY D
Authorized Official - Phone:787-852-9331
Mailing Address - Street 1:AA2 AVE TEJAS
Mailing Address - Street 2:CORREO VILLA PMB 132
Mailing Address - City:HUMACAO
Mailing Address - State:PR
Mailing Address - Zip Code:00791-4349
Mailing Address - Country:US
Mailing Address - Phone:787-852-9331
Mailing Address - Fax:787-719-4681
Practice Address - Street 1:CARR 908
Practice Address - Street 2:CALLE 26 BA4 BO. TEJAS
Practice Address - City:HUMACAO
Practice Address - State:PR
Practice Address - Zip Code:00791-4056
Practice Address - Country:US
Practice Address - Phone:787-852-9331
Practice Address - Fax:787-719-4681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-03
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3648261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PREW296AMedicare PIN