Healthcare Provider Details

I. General information

NPI: 1013158914
Provider Name (Legal Business Name): JUAN C OLMEDO LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2009
Last Update Date: 04/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 W 25TH ST APT 1B
NEW YORK NY
10001-6542
US

IV. Provider business mailing address

159 MADISON AVE APT 3I
NEW YORK NY
10016-5434
US

V. Phone/Fax

Practice location:
  • Phone: 646-449-0491
  • Fax:
Mailing address:
  • Phone: 646-696-7533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number72078317
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number080639
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: