Provider Demographics
NPI:1518758804
Name:MEDINA VAZQUEZ PSYCHOLOGIST LLC
Entity type:Organization
Organization Name:MEDINA VAZQUEZ PSYCHOLOGIST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENTE
Authorized Official - Prefix:
Authorized Official - First Name:AMNERIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDINA VAZQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DRA
Authorized Official - Phone:939-630-7208
Mailing Address - Street 1:PO BOX 591
Mailing Address - Street 2:
Mailing Address - City:MOCA
Mailing Address - State:PR
Mailing Address - Zip Code:00676-0591
Mailing Address - Country:US
Mailing Address - Phone:939-630-7208
Mailing Address - Fax:
Practice Address - Street 1:CARR 2 INT 417 EDF PUCHO POOL
Practice Address - Street 2:LOCAL 202 BASE #16 BO GUANABANO
Practice Address - City:AGUADA
Practice Address - State:PR
Practice Address - Zip Code:00602
Practice Address - Country:US
Practice Address - Phone:939-630-7208
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-15
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)