MEDICARE: MARK LEE OLIVER LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	102654	CA

General Provider Information

NPI Number	:	1497395958
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK LEE OLIVER LMFT

Provider Business Mailing Address
First Line	:	2616 ELLERHORST AVE
Second Line	:
City	:	EL CERRITO
State	:	CA
Zip	:	94530-1427
Country	:	US
Telephone Number	:	510-778-1585
Fax Number	:

Provider Business Practice Location Address
First Line	:	1199 SANCHEZ ST
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94114-3836
Country	:	US
Telephone Number	:	415-562-6201
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/13/2020
Last Update Date	:	01/13/2020

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