Provider Demographics
NPI:1871762526
Name:ROMAN- GANDULLA, SAMARI (PSYCHOLOGIST)
Entity type:Individual
Prefix:
First Name:SAMARI
Middle Name:
Last Name:ROMAN- GANDULLA
Suffix:
Gender:F
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 932
Mailing Address - Street 2:
Mailing Address - City:DORADO
Mailing Address - State:PR
Mailing Address - Zip Code:00646-0932
Mailing Address - Country:US
Mailing Address - Phone:787-649-7212
Mailing Address - Fax:
Practice Address - Street 1:1452 ASHFORD
Practice Address - Street 2:COND. ADALIGIA, SUITE 308
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00907-1581
Practice Address - Country:US
Practice Address - Phone:787-649-7212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-27
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3040103T00000X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologist