Provider Demographics
NPI:1841692415
Name:CENTRO DE LA TERCERA ONDA,CSP.
Entity type:Organization
Organization Name:CENTRO DE LA TERCERA ONDA,CSP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:787-636-4958
Mailing Address - Street 1:100 AMAZONA
Mailing Address - Street 2:URB EL PARAISO, PISO 2
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926
Mailing Address - Country:US
Mailing Address - Phone:787-510-9032
Mailing Address - Fax:
Practice Address - Street 1:100 AMAZONA
Practice Address - Street 2:URB EL PARAISO, PISO 2
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926
Practice Address - Country:US
Practice Address - Phone:787-510-9032
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3891103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1013241512OtherNPI
1013241512OtherNPI