Provider Demographics
NPI:1629512165
Name:OLIVARES, LETICIA CASANDRA (BCBA)
Entity Type:Individual
Prefix:
First Name:LETICIA
Middle Name:CASANDRA
Last Name:OLIVARES
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:CASSI
Other - Middle Name:
Other - Last Name:OLIVARES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7108 S KANNER HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-7462
Mailing Address - Country:US
Mailing Address - Phone:855-832-6727
Mailing Address - Fax:
Practice Address - Street 1:7215 BOSQUE BLVD
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-4020
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-16
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-16-24066103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst