Provider Demographics
NPI:1144630799
Name:OLIVER, MARTIN III (CADC-CAS)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:OLIVER
Suffix:III
Gender:M
Credentials:CADC-CAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 MELROSE AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-5506
Mailing Address - Country:US
Mailing Address - Phone:209-300-1512
Mailing Address - Fax:209-523-6912
Practice Address - Street 1:1235 MCHENRY AVE # SIUTESA
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-5370
Practice Address - Country:US
Practice Address - Phone:209-527-4597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-05
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARCAS-I 13533374700000X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No374700000XNursing Service Related ProvidersTechnician