Provider Demographics
NPI:1942030887
Name:PAGAN CUSTODIO, RUTH MILEIDY
Entity type:Individual
Prefix:
First Name:RUTH
Middle Name:MILEIDY
Last Name:PAGAN CUSTODIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:Y4 CALLE 22
Mailing Address - Street 2:
Mailing Address - City:CATANO
Mailing Address - State:PR
Mailing Address - Zip Code:00962-6410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:51 CALLE LAS FLORES
Practice Address - Street 2:
Practice Address - City:CATANO
Practice Address - State:PR
Practice Address - Zip Code:00962-4746
Practice Address - Country:US
Practice Address - Phone:787-944-9626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-06
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4532101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health