Healthcare Provider Details

I. General information

NPI: 1568021152
Provider Name (Legal Business Name): OLIVIA CARMEN OLMSTED AMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2019
Last Update Date: 06/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 STANDISH AVE
SANTA ROSA CA
95407-8113
US

IV. Provider business mailing address

1150 STAGE GULCH RD
PETALUMA CA
94954-9541
US

V. Phone/Fax

Practice location:
  • Phone: 707-234-5092
  • Fax: 707-585-6155
Mailing address:
  • Phone: 206-390-8520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number95201
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: