Provider Demographics
NPI:1013158914
Name:OLMEDO, JUAN C (LCSW)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:C
Last Name:OLMEDO
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 MADISON AVE APT 3I
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-5434
Mailing Address - Country:US
Mailing Address - Phone:646-696-7533
Mailing Address - Fax:
Practice Address - Street 1:412 W 25TH ST APT 1B
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-6542
Practice Address - Country:US
Practice Address - Phone:646-449-0491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-23
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY72078317101YM0800X
NY0806391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY058306OtherINTERNATIONAL BOARD FOR CERTIFICATION OF GROUP PSYCHOTHERAPISTS
NY080639OtherNYS OFFICE OF THE PROFESSIONS
72078317OtherNYS OFFICE OF THE PROFESSIONS