Provider Demographics
NPI:1073991600
Name:OLMOS, PRISCILLA (BS)
Entity Type:Individual
Prefix:MISS
First Name:PRISCILLA
Middle Name:
Last Name:OLMOS
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2456 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-1416
Mailing Address - Country:US
Mailing Address - Phone:619-817-1123
Mailing Address - Fax:
Practice Address - Street 1:13901 AMARGOSA RD
Practice Address - Street 2:SUITE 2
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-2409
Practice Address - Country:US
Practice Address - Phone:760-512-1925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-14
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB7949174103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst