Healthcare Provider Details

I. General information

NPI: 1619638475
Provider Name (Legal Business Name): ELSA IVONNE HERRERA OLIVERA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2022
Last Update Date: 01/04/2022
Certification Date: 01/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 RANCHEROS DR STE 166
SAN MARCOS CA
92069-2980
US

IV. Provider business mailing address

501 RUSH DR APT 7
SAN MARCOS CA
92078-7948
US

V. Phone/Fax

Practice location:
  • Phone: 760-744-3672
  • Fax:
Mailing address:
  • Phone: 760-270-3565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: