Provider Demographics
NPI:1942569413
Name:IRIZARRY, ROBERTO (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ROBERTO
Middle Name:
Last Name:IRIZARRY
Suffix:
Gender:M
Credentials:PSYD
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 1225
Mailing Address - Street 2:
Mailing Address - City:COAMO
Mailing Address - State:PR
Mailing Address - Zip Code:00769-1225
Mailing Address - Country:US
Mailing Address - Phone:787-649-6773
Mailing Address - Fax:
Practice Address - Street 1:CALLE CRUZ ORTIZ STELLA 126
Practice Address - Street 2:
Practice Address - City:HUMACAO
Practice Address - State:PR
Practice Address - Zip Code:00721
Practice Address - Country:US
Practice Address - Phone:787-649-6773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-03
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3887103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical