Provider Demographics
NPI:1821478710
Name:ONTIVEROS, GLENN (LMFT)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:ONTIVEROS
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1039
Mailing Address - Street 2:
Mailing Address - City:SAN LORENZO
Mailing Address - State:CA
Mailing Address - Zip Code:94580-5006
Mailing Address - Country:US
Mailing Address - Phone:707-297-9866
Mailing Address - Fax:
Practice Address - Street 1:55 SANTA CLARA AVE STE 200
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-1319
Practice Address - Country:US
Practice Address - Phone:707-297-9866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-04
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA96794106H00000X
HIH01297245390200000X
CALMFT124939106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program