Provider Demographics
NPI:1154965119
Name:MAGANA, OLIVIA ROSE
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:ROSE
Last Name:MAGANA
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 1:28500 BARN ROCK DR
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94542-2230
Mailing Address - Country:US
Mailing Address - Phone:209-747-1613
Mailing Address - Fax:
Practice Address - Street 1:39210 STATE ST STE 220
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1456
Practice Address - Country:US
Practice Address - Phone:510-894-4135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-03
Last Update Date:2019-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46-1305562106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician