Healthcare Provider Details

I. General information

NPI: 1851221527
Provider Name (Legal Business Name): MARK OLIVERAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2026
Last Update Date: 05/22/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2810 FRANK SCOTT PKWY W STE 812
BELLEVILLE IL
62223-5007
US

IV. Provider business mailing address

2810 FRANK SCOTT PKWY W STE 812
BELLEVILLE IL
62223-5007
US

V. Phone/Fax

Practice location:
  • Phone: 888-277-4028
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number166.012230
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: