Provider Demographics
NPI:1770051658
Name:GUADALUPE, SERGIO
Entity type:Individual
Prefix:
First Name:SERGIO
Middle Name:
Last Name:GUADALUPE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5623 PASEO MOREL CAMPOS
Mailing Address - Street 2:
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00728-2455
Mailing Address - Country:US
Mailing Address - Phone:787-812-2525
Mailing Address - Fax:
Practice Address - Street 1:B COND JARD DE SAN IGNACIO APT 1403
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00927-7030
Practice Address - Country:US
Practice Address - Phone:787-238-0615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-08
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR8161103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist