Provider Demographics
NPI:1922516004
Name:DOMENECH, DIANA TERESA (PSIC)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:TERESA
Last Name:DOMENECH
Suffix:
Gender:F
Credentials:PSIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MO17 PASEO DEL VALLE
Mailing Address - Street 2:
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00961-3539
Mailing Address - Country:US
Mailing Address - Phone:787-467-8878
Mailing Address - Fax:
Practice Address - Street 1:MO17 PASEO DEL VALLE
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961-3539
Practice Address - Country:US
Practice Address - Phone:787-467-8878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-11
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5920103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR5920OtherPSIC NUMBER