Provider Demographics
NPI:1528316643
Name:REDWINE, OLIVIA GAIL (LMFT)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:GAIL
Last Name:REDWINE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:MS
Other - First Name:LIBBY
Other - Middle Name:
Other - Last Name:REDWINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5078 SANTA ROSA CREEK RD
Mailing Address - Street 2:
Mailing Address - City:CAMBRIA
Mailing Address - State:CA
Mailing Address - Zip Code:93428-3518
Mailing Address - Country:US
Mailing Address - Phone:805-927-4566
Mailing Address - Fax:
Practice Address - Street 1:800 HILLCREST DR
Practice Address - Street 2:#5
Practice Address - City:CAMBRIA
Practice Address - State:CA
Practice Address - Zip Code:93428-2840
Practice Address - Country:US
Practice Address - Phone:805-203-3045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-21
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC29222106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist