Provider Demographics
NPI:1316977069
Name:OLIVARES, MARTIN H (MFT, PHD)
Entity type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:H
Last Name:OLIVARES
Suffix:
Gender:M
Credentials:MFT, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 N HAYWORTH AVE
Mailing Address - Street 2:APT. #1
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-3631
Mailing Address - Country:US
Mailing Address - Phone:310-993-0557
Mailing Address - Fax:213-201-1392
Practice Address - Street 1:152 S LASKY DR
Practice Address - Street 2:SUITE 208
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90212-1720
Practice Address - Country:US
Practice Address - Phone:310-993-0557
Practice Address - Fax:213-201-1392
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38080103TP0814X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA550010006509OtherPACIFIC CARE
CA380800OtherBLUESHIELD OF CALIFORNIA