Individual
MR. EDWARD OMAR ONTIVEROS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LAC
Contact information
Practice address
4801 S LAKESHORE DR STE 106, TEMPE, AZ 85282-7156
(480) 525-0058
Mailing address
3924 E MINTON ST, PHOENIX, AZ 85042-6229
(602) 821-9386
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
LAC-21115
AZ
Other
Enumeration date
09/20/2022
Last updated
09/20/2022
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