Provider Demographics
NPI:1366009730
Name:CARMONA, OLGA EDITH
Entity type:Individual
Prefix:
First Name:OLGA
Middle Name:EDITH
Last Name:CARMONA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:OLGA
Other - Middle Name:
Other - Last Name:GILLAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4760 35TH ST APT 5
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-2486
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10201 MISSION GORGE RD STE O
Practice Address - Street 2:
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071-3040
Practice Address - Country:US
Practice Address - Phone:619-383-6868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-21
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health