Provider Demographics
NPI:1477893170
Name:OLIVEIRA, MEGAN GRACE
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:GRACE
Last Name:OLIVEIRA
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 1:1909 KINSLEY ST
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-3009
Mailing Address - Country:US
Mailing Address - Phone:916-834-0378
Mailing Address - Fax:
Practice Address - Street 1:505
Practice Address - Street 2:505 SAN MARIN DR. SUITE 100B
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945
Practice Address - Country:US
Practice Address - Phone:707-799-9527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-18
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12152766103K00000X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist