Provider Demographics
NPI:1558864017
Name:GONZALES-OLIVA, MYRIAH RAE
Entity Type:Individual
Prefix:
First Name:MYRIAH
Middle Name:RAE
Last Name:GONZALES-OLIVA
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 1:6603 ADAINVILLE DR
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93552-3527
Mailing Address - Country:US
Mailing Address - Phone:661-522-1185
Mailing Address - Fax:
Practice Address - Street 1:23824 HAWTHORNE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-5935
Practice Address - Country:US
Practice Address - Phone:310-791-3064
Practice Address - Fax:310-791-3084
Is Sole Proprietor?:No
Enumeration Date:2018-03-12
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF95441101YM0800X
CAAMFT135672106H00000X
CAAMFT95441106H00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator