Healthcare Provider Details

I. General information

NPI: 1831036037
Provider Name (Legal Business Name): NISSA ONTIVEROS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: LEO ONTIVEROS

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6112 GOULD AVE S
SEATTLE WA
98108-2959
US

IV. Provider business mailing address

6516 39TH AVE SW
SEATTLE WA
98136-1804
US

V. Phone/Fax

Practice location:
  • Phone: 206-659-7246
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: