Provider Demographics
NPI:1942321005
Name:DIAZGONZALEZ, REBECA (LCDA)
Entity Type:Individual
Prefix:MRS
First Name:REBECA
Middle Name:
Last Name:DIAZGONZALEZ
Suffix:
Gender:F
Credentials:LCDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 261
Mailing Address - Street 2:
Mailing Address - City:HUMACAO
Mailing Address - State:PR
Mailing Address - Zip Code:00792-0261
Mailing Address - Country:US
Mailing Address - Phone:787-656-5818
Mailing Address - Fax:787-374-8181
Practice Address - Street 1:CALLE 24 S 1
Practice Address - Street 2:URB. VILLA UNIVERSITARIA
Practice Address - City:HUMACAO
Practice Address - State:PR
Practice Address - Zip Code:00791
Practice Address - Country:US
Practice Address - Phone:787-656-5818
Practice Address - Fax:787-374-8181
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2247103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR563468Medicare UPIN
PR219099Medicare UPIN
PR3251Medicare UPIN