Healthcare Provider Details

I. General information

NPI: 1740802362
Provider Name (Legal Business Name): CARLOS ALEXIS SEPULVEDA MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2020
Last Update Date: 05/18/2020
Certification Date: 05/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

C-17 CALLE MARGINAL SANTA CRUZ
BAYAMON PR
00961
US

IV. Provider business mailing address

URB. FAIRVIEW CALLE 2 B 20
SAN JUAN PR
00926-8140
US

V. Phone/Fax

Practice location:
  • Phone: 787-785-9381
  • Fax:
Mailing address:
  • Phone: 787-432-8268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number23625
License Number StatePR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: