Provider Demographics
NPI:1942760442
Name:OLIVARES, LAUREN DANIELLE
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:DANIELLE
Last Name:OLIVARES
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 1:2105 MESCALERO LOOP APT B
Mailing Address - Street 2:
Mailing Address - City:HOLLOMAN AFB
Mailing Address - State:NM
Mailing Address - Zip Code:88330-7653
Mailing Address - Country:US
Mailing Address - Phone:559-759-8346
Mailing Address - Fax:
Practice Address - Street 1:2105 MESCALERO LOOP APT B
Practice Address - Street 2:
Practice Address - City:HOLLOMAN AFB
Practice Address - State:NM
Practice Address - Zip Code:88330-7653
Practice Address - Country:US
Practice Address - Phone:559-759-8346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-21
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician