Healthcare Provider Details

I. General information

NPI: 1275403800
Provider Name (Legal Business Name): CARLOS OLMOS LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2025
Last Update Date: 11/08/2025
Certification Date: 11/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1109 W SAN BERNARDINO RD STE 150
COVINA CA
91722-4156
US

IV. Provider business mailing address

1954 WELLESLEY RD
SAN MARINO CA
91108-3037
US

V. Phone/Fax

Practice location:
  • Phone: 626-541-0009
  • Fax:
Mailing address:
  • Phone: 626-541-0009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number21730
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: