Provider Demographics
NPI:1366930133
Name:PSY CLINIC LLC
Entity type:Organization
Organization Name:PSY CLINIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JACKELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:VELEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-813-2222
Mailing Address - Street 1:PO BOX 560
Mailing Address - Street 2:
Mailing Address - City:MERCEDITA
Mailing Address - State:PR
Mailing Address - Zip Code:00715-0560
Mailing Address - Country:US
Mailing Address - Phone:787-813-2222
Mailing Address - Fax:
Practice Address - Street 1:LEGACY OFFICE PARK
Practice Address - Street 2:SUITE 102
Practice Address - City:COTO LAUREL
Practice Address - State:PR
Practice Address - Zip Code:00780
Practice Address - Country:US
Practice Address - Phone:787-813-2222
Practice Address - Fax:787-813-2222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-27
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1902055023Medicaid