Provider Demographics
NPI:1053929018
Name:NEGRON, MAITE IVELISSE (PSYD)
Entity type:Individual
Prefix:
First Name:MAITE
Middle Name:IVELISSE
Last Name:NEGRON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60026 CALLE NARANJO
Mailing Address - Street 2:
Mailing Address - City:DORADO
Mailing Address - State:PR
Mailing Address - Zip Code:00646-9673
Mailing Address - Country:US
Mailing Address - Phone:787-615-4503
Mailing Address - Fax:
Practice Address - Street 1:6 CALLE JOSE DE DIEGO
Practice Address - Street 2:
Practice Address - City:CIALES
Practice Address - State:PR
Practice Address - Zip Code:00638-3214
Practice Address - Country:US
Practice Address - Phone:787-871-0356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-16
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5698103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty