Provider Demographics
NPI:1457074098
Name:ONTIVEROS, EDWARD OMAR (LAC)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:OMAR
Last Name:ONTIVEROS
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3924 E MINTON ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-6229
Mailing Address - Country:US
Mailing Address - Phone:602-821-9386
Mailing Address - Fax:
Practice Address - Street 1:4801 S LAKESHORE DR STE 106
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7156
Practice Address - Country:US
Practice Address - Phone:480-525-0058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-21115101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health