Provider Demographics
NPI:1972155711
Name:OLIVARES, DOMINIQUE ANGEL
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:ANGEL
Last Name:OLIVARES
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:724 WILLIAMS AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95838-3309
Mailing Address - Country:US
Mailing Address - Phone:916-807-3090
Mailing Address - Fax:
Practice Address - Street 1:724 WILLIAMS AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95838-3309
Practice Address - Country:US
Practice Address - Phone:916-807-3090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician