Provider Demographics
NPI:1578087565
Name:OLVERA, MARK DION
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:DION
Last Name:OLVERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4652 S ELKRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85730-5012
Mailing Address - Country:US
Mailing Address - Phone:520-979-4254
Mailing Address - Fax:
Practice Address - Street 1:3601 S 6TH AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85723-0001
Practice Address - Country:US
Practice Address - Phone:520-979-4254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-01
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty