Basic Information
| Provider Information | |||||||||
| NPI: | 1821478710 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ONTIVEROS | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 170 S SPRUCE AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | SOUTH SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940804557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6508326900 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 170 S SPRUCE AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | SOUTH SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940804557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6508326900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2015 | ||||||||
| LastUpdateDate: | 04/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 96794 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 390200000X | H01297245 | HI | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 106H00000X | LMFT124939 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.