Provider Demographics
NPI:1548309123
Name:OLIVELLA VIVES, ENRIQUE ALFREDO (MFT)
Entity type:Individual
Prefix:MR
First Name:ENRIQUE
Middle Name:ALFREDO
Last Name:OLIVELLA VIVES
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:849 DIVISADERO ST APT 2
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94117-1515
Mailing Address - Country:US
Mailing Address - Phone:415-571-3306
Mailing Address - Fax:
Practice Address - Street 1:650 CLARK WAY
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-2300
Practice Address - Country:US
Practice Address - Phone:650-688-3626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 50253106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0OtherM.F.T TRAINEE