MEDICARE: GRACIELA OLIVER

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1588396436
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACIELA OLIVER

Provider Business Mailing Address
First Line	:	76968 FLORIDA AVE
Second Line	:
City	:	PALM DESERT
State	:	CA
Zip	:	92211-7712
Country	:	US
Telephone Number	:	801-462-6236
Fax Number	:

Provider Business Practice Location Address
First Line	:	6117 BROCKTON AVE
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-2232
Country	:	US
Telephone Number	:	951-481-6402
Fax Number	:

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

Provider Enumeration Date	:	06/29/2022
Last Update Date	:	06/29/2022

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