Provider Demographics
NPI:1518603851
Name:OSTOLAZA, OMAR
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:OSTOLAZA
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 9809
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00726-9809
Mailing Address - Country:US
Mailing Address - Phone:787-704-0705
Mailing Address - Fax:787-744-7444
Practice Address - Street 1:431 AVE HOSTOS
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918-3014
Practice Address - Country:US
Practice Address - Phone:787-704-0705
Practice Address - Fax:787-744-7444
Is Sole Proprietor?:No
Enumeration Date:2022-05-10
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7222103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling