Healthcare Provider Details

I. General information

NPI: 1306331228
Provider Name (Legal Business Name): EDNA MARIANA OLIVARES GOMEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2018
Last Update Date: 06/10/2021
Certification Date: 06/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1333 WILLOW PASS RD STE 102
CONCORD CA
94520-5225
US

IV. Provider business mailing address

5776 STONERIDGE MALL RD STE 340
PLEASANTON CA
94588-4514
US

V. Phone/Fax

Practice location:
  • Phone: 510-745-9151
  • Fax:
Mailing address:
  • Phone: 925-223-8047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number125285
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: