Provider Demographics
NPI:1780243899
Name:DIANA, MARELY (PHD, MA)
Entity type:Individual
Prefix:DR
First Name:MARELY
Middle Name:
Last Name:DIANA
Suffix:
Gender:F
Credentials:PHD, MA
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 41
Mailing Address - Street 2:
Mailing Address - City:GUAYAMA
Mailing Address - State:PR
Mailing Address - Zip Code:00785-0041
Mailing Address - Country:US
Mailing Address - Phone:787-469-2111
Mailing Address - Fax:
Practice Address - Street 1:CALLE PALMER #6 ESQUINA NORTE, FRANCISCO G. BRUNO
Practice Address - Street 2:
Practice Address - City:GUAYAMA
Practice Address - State:PR
Practice Address - Zip Code:00784
Practice Address - Country:US
Practice Address - Phone:787-469-2111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-12
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5789103T00000X, 103TH0004X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR5789OtherPROFESIONAL PRACTICE LICENSE
PR5789OtherJUNTA EXAMINADORA DE PSICOLOGOS DE PR