Provider Demographics
NPI:1790866515
Name:ONTIVEROS, LOURDES THERESA
Entity type:Individual
Prefix:MISS
First Name:LOURDES
Middle Name:THERESA
Last Name:ONTIVEROS
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 1:1095 N MAIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92867-5476
Mailing Address - Country:US
Mailing Address - Phone:714-633-0502
Mailing Address - Fax:714-633-9249
Practice Address - Street 1:1095 N MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92867-5476
Practice Address - Country:US
Practice Address - Phone:714-633-0502
Practice Address - Fax:714-633-9249
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5370101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)