Provider Demographics
NPI:1295968915
Name:BURGOS MERCADO, MARISELL (PHD)
Entity type:Individual
Prefix:DR
First Name:MARISELL
Middle Name:
Last Name:BURGOS MERCADO
Suffix:
Gender:F
Credentials:PHD
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 190705
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00919-0705
Mailing Address - Country:US
Mailing Address - Phone:787-390-7474
Mailing Address - Fax:
Practice Address - Street 1:1290 CALLE 54 SE
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00921-3141
Practice Address - Country:US
Practice Address - Phone:787-664-3816
Practice Address - Fax:620-506-4381
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-27
Last Update Date:2020-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2047103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical