Provider Demographics
NPI:1770785057
Name:MARRERO, IVAN A (MA)
Entity type:Individual
Prefix:MR
First Name:IVAN
Middle Name:A
Last Name:MARRERO
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CALLE UNION 664
Mailing Address - Street 2:APTO. 205
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00907
Mailing Address - Country:US
Mailing Address - Phone:787-723-1030
Mailing Address - Fax:
Practice Address - Street 1:CALL BOX 4964
Practice Address - Street 2:
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00726-4964
Practice Address - Country:US
Practice Address - Phone:787-653-0550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2125103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling