Provider Demographics
NPI:1245864081
Name:LOPEZ CRESPO, RAQUEL IVELISSE (PSIC)
Entity type:Individual
Prefix:MRS
First Name:RAQUEL
Middle Name:IVELISSE
Last Name:LOPEZ CRESPO
Suffix:
Gender:F
Credentials:PSIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:VILLAS DE LOIZA
Mailing Address - Street 2:CALLE 28A TT21
Mailing Address - City:CANOVANAS
Mailing Address - State:PR
Mailing Address - Zip Code:00729
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:ENRIQUE MANGUAL CANOVANAS MALL
Practice Address - Street 2:OFICINA LOCAL 14
Practice Address - City:CANOVANAS
Practice Address - State:PR
Practice Address - Zip Code:00729
Practice Address - Country:US
Practice Address - Phone:787-344-1277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-02
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6375103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist