Provider Demographics
NPI:1700598570
Name:LICIAGA-LOPEZ, ZAIMARY (PSYD)
Entity Type:Individual
Prefix:
First Name:ZAIMARY
Middle Name:
Last Name:LICIAGA-LOPEZ
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 1:212 EXT LAMELA
Mailing Address - Street 2:
Mailing Address - City:QUEBRADILLAS
Mailing Address - State:PR
Mailing Address - Zip Code:00678-1722
Mailing Address - Country:US
Mailing Address - Phone:787-895-7238
Mailing Address - Fax:
Practice Address - Street 1:CARR 477 BO CACAO C/II WILLIAM LOPEZ
Practice Address - Street 2:
Practice Address - City:QUEBRADILLAS
Practice Address - State:PR
Practice Address - Zip Code:00678
Practice Address - Country:US
Practice Address - Phone:787-895-7238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-23
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7557103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical