Provider Demographics
NPI:1306331228
Name:OLIVARES GOMEZ, EDNA MARIANA
Entity type:Individual
Prefix:
First Name:EDNA
Middle Name:MARIANA
Last Name:OLIVARES GOMEZ
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 1:5776 STONERIDGE MALL RD STE 340
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94588-4514
Mailing Address - Country:US
Mailing Address - Phone:925-223-8047
Mailing Address - Fax:
Practice Address - Street 1:1333 WILLOW PASS RD STE 102
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-5225
Practice Address - Country:US
Practice Address - Phone:510-745-9151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-23
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA125285106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA96758262G57299Medicaid