Provider Demographics
NPI:1376943506
Name:OLIVOS, LAURA S (PSY D)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:S
Last Name:OLIVOS
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8129 ABBOTT AVE APT 12
Mailing Address - Street 2:
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33141-1658
Mailing Address - Country:US
Mailing Address - Phone:772-240-9599
Mailing Address - Fax:305-675-0689
Practice Address - Street 1:975 ARTHUR GODFREY RD STE 303
Practice Address - Street 2:
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33140-3342
Practice Address - Country:US
Practice Address - Phone:305-792-8168
Practice Address - Fax:305-675-0689
Is Sole Proprietor?:No
Enumeration Date:2014-08-25
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY9816103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021870400Medicaid