Healthcare Provider Details

I. General information

NPI: 1285065045
Provider Name (Legal Business Name): OLGA REYNA REQUENEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2013
Last Update Date: 07/11/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1265 FURUKAWA WAY
SANTA MARIA CA
93458-4929
US

IV. Provider business mailing address

401 E CYPRESS AVE
LOMPOC CA
93436-6806
US

V. Phone/Fax

Practice location:
  • Phone: 805-614-4940
  • Fax: 805-614-0179
Mailing address:
  • Phone: 805-865-1940
  • Fax: 805-865-1954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: