Provider Demographics
NPI:1205319498
Name:DOMENECH-DE LA ROSA, ILEANA (PSYD)
Entity type:Individual
Prefix:
First Name:ILEANA
Middle Name:
Last Name:DOMENECH-DE LA ROSA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:ILEANA
Other - Middle Name:
Other - Last Name:DOMENECH-DE LA ROSA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 190100
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00919-0100
Mailing Address - Country:US
Mailing Address - Phone:787-688-4664
Mailing Address - Fax:
Practice Address - Street 1:CONDOMINIO PARQUE CENTRO
Practice Address - Street 2:APT L15
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918
Practice Address - Country:US
Practice Address - Phone:787-688-4664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-13
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5919103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist