Healthcare Provider Details

I. General information

NPI: 1245616804
Provider Name (Legal Business Name): DIANE RODRIGUEZ OLVERA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2015
Last Update Date: 03/31/2023
Certification Date: 03/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11565 LAUREL CANYON BLVD STE 116
SAN FERNANDO CA
91340-4650
US

IV. Provider business mailing address

11565 LAUREL CANYON BLVD STE 116
SAN FERNANDO CA
91340-4650
US

V. Phone/Fax

Practice location:
  • Phone: 818-361-5030
  • Fax:
Mailing address:
  • Phone: 818-361-5030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number72200
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number72200
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number114588
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: