Provider Demographics
NPI:1184060410
Name:MATIAS PADILLA, INDRID JANETTE
Entity type:Individual
Prefix:
First Name:INDRID
Middle Name:JANETTE
Last Name:MATIAS PADILLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CALLE DE DIEGO
Mailing Address - Street 2:#54-B ESTE BAJO
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00680
Mailing Address - Country:US
Mailing Address - Phone:787-439-1976
Mailing Address - Fax:
Practice Address - Street 1:CALLE DE DIEGO E
Practice Address - Street 2:#54-B ESTE BAJO
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680-4866
Practice Address - Country:US
Practice Address - Phone:787-439-1976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-14
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3589103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist