Provider Demographics
NPI:1548954324
Name:OLIVARES, DIANA
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:OLIVARES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5850 GRANITE PKWY STE 600
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-6753
Mailing Address - Country:US
Mailing Address - Phone:469-694-1754
Mailing Address - Fax:
Practice Address - Street 1:1212 MARSH ST STE 1
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-3346
Practice Address - Country:US
Practice Address - Phone:805-703-2120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-06
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician