Provider Demographics
NPI:1457690034
Name:ALVARADO SANTIAGO, IVELISSE
Entity Type:Individual
Prefix:
First Name:IVELISSE
Middle Name:
Last Name:ALVARADO SANTIAGO
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:HC 1 BOX 10364
Mailing Address - Street 2:
Mailing Address - City:PENUELAS
Mailing Address - State:PR
Mailing Address - Zip Code:00624-9729
Mailing Address - Country:US
Mailing Address - Phone:787-316-7897
Mailing Address - Fax:
Practice Address - Street 1:LEGACY OFFICE PARK, SUITE 102
Practice Address - Street 2:COTO LAUREL, PR
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00780
Practice Address - Country:US
Practice Address - Phone:787-813-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-03
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2927103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical