Provider Demographics
NPI:1316411721
Name:CASILLAS CANALES, GRETCHEN NICOLE (PSYM)
Entity type:Individual
Prefix:MRS
First Name:GRETCHEN
Middle Name:NICOLE
Last Name:CASILLAS CANALES
Suffix:
Gender:F
Credentials:PSYM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:718 CALLE CIPRES
Mailing Address - Street 2:URB HIGHLAND PARK
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00924
Mailing Address - Country:US
Mailing Address - Phone:787-248-0486
Mailing Address - Fax:
Practice Address - Street 1:416 AVE PONCE DE LEON STE 912
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918-3425
Practice Address - Country:US
Practice Address - Phone:787-248-0486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-18
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6190103T00000X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty