Provider Demographics
NPI:1912565334
Name:OLETA, LISANDRO EZEQUIEL
Entity type:Individual
Prefix:
First Name:LISANDRO
Middle Name:EZEQUIEL
Last Name:OLETA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 W CAMERON AVE STE 215
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-2724
Mailing Address - Country:US
Mailing Address - Phone:323-302-9997
Mailing Address - Fax:818-736-4189
Practice Address - Street 1:1501 W CAMERON AVE STE 215
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-2724
Practice Address - Country:US
Practice Address - Phone:323-302-9997
Practice Address - Fax:818-736-4189
Is Sole Proprietor?:No
Enumeration Date:2019-05-31
Last Update Date:2025-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst