Provider Demographics
NPI:1114382348
Name:OLIVO, MARIA (PTA)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:OLIVO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14649 SHADY VALLEY WAY
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-5736
Mailing Address - Country:US
Mailing Address - Phone:323-365-1356
Mailing Address - Fax:
Practice Address - Street 1:14649 SHADY VALLEY WAY
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-5736
Practice Address - Country:US
Practice Address - Phone:323-365-1356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-14
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT8501225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant