Healthcare Provider Details

I. General information

NPI: 1467397737
Provider Name (Legal Business Name): KATHLEEN OLIVAREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2026
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1448 E CENTER ST STE A1
POCATELLO ID
83201-4132
US

IV. Provider business mailing address

875 W 150 N
BLACKFOOT ID
83221-5372
US

V. Phone/Fax

Practice location:
  • Phone: 208-220-6891
  • Fax:
Mailing address:
  • Phone: 208-220-6891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCOUI-9713
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: