Provider Demographics
NPI:1457908063
Name:BURGOS MARTINEZ, MARIZEL (PSYD)
Entity type:Individual
Prefix:MRS
First Name:MARIZEL
Middle Name:
Last Name:BURGOS MARTINEZ
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 10734
Mailing Address - Street 2:CAPARRA HEIGHTS STATION
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00922-0734
Mailing Address - Country:US
Mailing Address - Phone:939-402-1334
Mailing Address - Fax:
Practice Address - Street 1:867 AVE MUNOZ RIVERA STE B102
Practice Address - Street 2:
Practice Address - City:RIO PIEDRAS
Practice Address - State:PR
Practice Address - Zip Code:00925-2109
Practice Address - Country:US
Practice Address - Phone:939-402-1334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-20
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5768103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical