Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TC1900X | Counseling Psychologist | 3569 | PR |
NPI | 1023579844 |
---|---|
Provider Name | Dr. Suly Dairay Illas Mendez |
First Address | Moca, PR 00676-8263 |
Second Address | Moca, PR 00676-0067 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/03/2019 |
Last Update Date | 03/01/2020 |