Provider Demographics
NPI:1245938018
Name:CARABALLO RODRIGUEZ, CARMEN B
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:B
Last Name:CARABALLO RODRIGUEZ
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:J2 CALLE SANDALO
Mailing Address - Street 2:JARDINES FAGOT
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00716
Mailing Address - Country:US
Mailing Address - Phone:787-616-1714
Mailing Address - Fax:
Practice Address - Street 1:2961 AVE. ROOSEVELT A-1
Practice Address - Street 2:URB. MARIANI
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717
Practice Address - Country:US
Practice Address - Phone:787-438-3117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-21
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7505103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical