Healthcare Provider Details

I. General information

NPI: 1427275148
Provider Name (Legal Business Name): MARIO OLAVARRIA PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 08/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 NW 12TH AVE
MIAMI FL
33136-1005
US

IV. Provider business mailing address

7910 SW 97TH PL
MIAMI FL
33173-3164
US

V. Phone/Fax

Practice location:
  • Phone: 305-585-1252
  • Fax:
Mailing address:
  • Phone: 305-724-5570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY6113
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License NumberPY6113
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License NumberPY6113
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: