Provider Demographics
NPI:1992831002
Name:ROSARIO, IVAN (MA)
Entity Type:Individual
Prefix:MR
First Name:IVAN
Middle Name:
Last Name:ROSARIO
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 CALLE CORAL
Mailing Address - Street 2:COCO BEACH
Mailing Address - City:RIO GRANDE
Mailing Address - State:PR
Mailing Address - Zip Code:00745-4623
Mailing Address - Country:US
Mailing Address - Phone:939-969-5396
Mailing Address - Fax:
Practice Address - Street 1:1324 AVE FD ROOSEVELT
Practice Address - Street 2:SUITE 201
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00920-2809
Practice Address - Country:US
Practice Address - Phone:787-792-0278
Practice Address - Fax:787-792-7994
Is Sole Proprietor?:No
Enumeration Date:2007-02-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR743103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist