Provider Demographics
NPI:1992008817
Name:GONZALEZ, MYRIAM (PSY D)
Entity Type:Individual
Prefix:DR
First Name:MYRIAM
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CONDOMINIO PLAYA DORADA APARTAMENTO 616 B
Mailing Address - Street 2:7043 CARRETERA 187
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00979
Mailing Address - Country:UM
Mailing Address - Phone:787-536-1317
Mailing Address - Fax:787-200-5149
Practice Address - Street 1:CONDOMINIO PLAYA DORADA APARTAMENTO 616 B
Practice Address - Street 2:7043 CARRETERA 187
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00979
Practice Address - Country:UM
Practice Address - Phone:787-536-1317
Practice Address - Fax:787-200-5149
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-15
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR678103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical