MEDICARE: KRISTINE TERESA OLIVAS MFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	44428	CA
2	106H00000X	Marriage & Family Therapist	166.000734	IL

General Provider Information

NPI Number	:	1407989072
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTINE TERESA OLIVAS MFT

Provider Business Mailing Address
First Line	:	11164 S SAINT LOUIS AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60655-3521
Country	:	US
Telephone Number	:	773-957-5352
Fax Number	:

Provider Business Practice Location Address
First Line	:	11164 S SAINT LOUIS AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60655-3521
Country	:	US
Telephone Number	:	773-957-5352
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/13/2007
Last Update Date	:	01/12/2009

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