Provider Demographics
NPI:1003317306
Name:OLIVARES CHAYEB, RAFAEL ELIAS
Entity type:Individual
Prefix:DR
First Name:RAFAEL
Middle Name:ELIAS
Last Name:OLIVARES CHAYEB
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 1:1260 MORENA BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-3850
Mailing Address - Country:US
Mailing Address - Phone:619-398-0355
Mailing Address - Fax:619-398-0350
Practice Address - Street 1:480 ALTA RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92179-0001
Practice Address - Country:US
Practice Address - Phone:619-691-6947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-22
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X, 172V00000X, 390200000X
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No172V00000XOther Service ProvidersCommunity Health Worker