Provider Demographics
NPI:1699340778
Name:SEDA OLMO, JOEL JOSE
Entity type:Individual
Prefix:
First Name:JOEL
Middle Name:JOSE
Last Name:SEDA OLMO
Suffix:
Gender:M
Credentials:
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 6206
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00681-6206
Mailing Address - Country:US
Mailing Address - Phone:787-313-1524
Mailing Address - Fax:
Practice Address - Street 1:CARR 111 KM 24.0 INT. BO. PIEDRAS BLANCAS
Practice Address - Street 2:
Practice Address - City:SAN SEBASTIAN
Practice Address - State:PR
Practice Address - Zip Code:00685
Practice Address - Country:US
Practice Address - Phone:787-313-1524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-21
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR05201358101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR4125130OtherLICENSE
PR4125130Medicaid