Provider Demographics
NPI:1639672751
Name:OQUENDO, ILDEFONSO ALFONSO JR (CASAC-T)
Entity Type:Individual
Prefix:MR
First Name:ILDEFONSO
Middle Name:ALFONSO
Last Name:OQUENDO
Suffix:JR
Gender:M
Credentials:CASAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:172 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12550-4912
Mailing Address - Country:US
Mailing Address - Phone:845-561-5783
Mailing Address - Fax:
Practice Address - Street 1:172 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-4912
Practice Address - Country:US
Practice Address - Phone:845-561-5783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-15
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY31597101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)