Provider Demographics
NPI:1619334885
Name:OLIVA, TEODORICO JOSEPH III (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:TEODORICO
Middle Name:JOSEPH
Last Name:OLIVA
Suffix:III
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7137 SHOUP AVE UNIT 9
Mailing Address - Street 2:
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91307-2336
Mailing Address - Country:US
Mailing Address - Phone:213-268-2408
Mailing Address - Fax:
Practice Address - Street 1:22125 ROSCOE BLVD
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91304-3839
Practice Address - Country:US
Practice Address - Phone:213-268-2408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-19
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7051225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist