Provider Demographics
NPI:1114316916
Name:OLIVARES, WILLIAM GERARDO
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:GERARDO
Last Name:OLIVARES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5131 N 40TH ST
Mailing Address - Street 2:APT A210
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-2117
Mailing Address - Country:US
Mailing Address - Phone:520-429-7123
Mailing Address - Fax:
Practice Address - Street 1:6306 N 7TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-1549
Practice Address - Country:US
Practice Address - Phone:602-279-5801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-16
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA92392355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant