Healthcare Provider Details

I. General information

NPI: 1164580957
Provider Name (Legal Business Name): CIRO THOMAS OLIVARES MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 WAVERLY AVENUE
PITTSFIELD ME
04967
US

IV. Provider business mailing address

12 WAVERLY AVE
PITTSFIELD ME
04967-1118
US

V. Phone/Fax

Practice location:
  • Phone: 207-623-8411
  • Fax:
Mailing address:
  • Phone: 207-623-8411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC1228
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: