Provider Demographics
NPI:1174760516
Name:OLIVER, KATHLEEN M (LCSW)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:M
Last Name:OLIVER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 365
Mailing Address - Street 2:
Mailing Address - City:CAYUCOS
Mailing Address - State:CA
Mailing Address - Zip Code:93430-0365
Mailing Address - Country:US
Mailing Address - Phone:805-710-1031
Mailing Address - Fax:805-995-1965
Practice Address - Street 1:24 CYPRESS GLEN CT
Practice Address - Street 2:
Practice Address - City:CAYUCOS
Practice Address - State:CA
Practice Address - Zip Code:93430-1158
Practice Address - Country:US
Practice Address - Phone:805-710-1031
Practice Address - Fax:805-995-1965
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-07
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA233881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1174760516Medicaid
CADS501AMedicare PIN
CA10242015100056-001Medicare PIN