Provider Demographics
NPI:1225788292
Name:SANCHEZ OLIVARES, SUSANA
Entity Type:Individual
Prefix:MISS
First Name:SUSANA
Middle Name:
Last Name:SANCHEZ 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 1:1710 EVERGLADES BLVD N
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34120-5515
Mailing Address - Country:US
Mailing Address - Phone:832-322-1197
Mailing Address - Fax:
Practice Address - Street 1:3720 19TH AVE SW
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34117-6142
Practice Address - Country:US
Practice Address - Phone:305-815-6167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-24
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB688998106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL11209100Medicaid