Provider Demographics
NPI:1992373716
Name:MERCADO JIMENEZ, LARISSA SUZETTE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LARISSA
Middle Name:SUZETTE
Last Name:MERCADO JIMENEZ
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 AVE GONZALEZ CLEMENTE STE 304
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00682-1107
Mailing Address - Country:US
Mailing Address - Phone:787-560-6178
Mailing Address - Fax:
Practice Address - Street 1:445 AVE GONZALEZ CLEMENTE STE 215
Practice Address - Street 2:
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00682-1107
Practice Address - Country:US
Practice Address - Phone:939-525-3222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-16
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6834103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical