Provider Demographics
NPI:1295781102
Name:CANDELARIO, MYRNA J (PSYD)
Entity type:Individual
Prefix:MR
First Name:MYRNA
Middle Name:J
Last Name:CANDELARIO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 367221
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00936-7221
Mailing Address - Country:US
Mailing Address - Phone:787-708-9871
Mailing Address - Fax:787-296-0720
Practice Address - Street 1:435 AVE HOSTOS
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918-3014
Practice Address - Country:US
Practice Address - Phone:787-708-9871
Practice Address - Fax:787-296-0720
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1086103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA82247LMedicare ID - Type UnspecifiedMEDICARE GROUP PROVIDER
PRS32038Medicare UPIN
PR91229GMedicare ID - Type UnspecifiedMEDICARE GROUP PROVIDER N
PR85046CMedicare ID - Type UnspecifiedMEDICARE GROUP PROVIDER N
PR91230FMedicare ID - Type UnspecifiedMEDICARE GROUP PROVIDER N
PR87663Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER