Provider Demographics
NPI:1245616804
Name:OLVERA, DIANE RODRIGUEZ
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:RODRIGUEZ
Last Name:OLVERA
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 1:11565 LAUREL CANYON BLVD STE 116
Mailing Address - Street 2:
Mailing Address - City:SAN FERNANDO
Mailing Address - State:CA
Mailing Address - Zip Code:91340-4650
Mailing Address - Country:US
Mailing Address - Phone:818-361-5030
Mailing Address - Fax:
Practice Address - Street 1:11565 LAUREL CANYON BLVD STE 116
Practice Address - Street 2:
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340-4650
Practice Address - Country:US
Practice Address - Phone:818-361-5030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-06
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA72200104100000X, 1041C0700X
1041C0700X
CA1145881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker