Provider Demographics
NPI:1720746605
Name:OLIVENCIA, JOSE ENRIQUE (OTR/L)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:ENRIQUE
Last Name:OLIVENCIA
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 HIDDEN OAK PL
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-4866
Mailing Address - Country:US
Mailing Address - Phone:502-608-5978
Mailing Address - Fax:
Practice Address - Street 1:2100 MILLVALE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-1604
Practice Address - Country:US
Practice Address - Phone:502-451-0990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-07
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY131789225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist