MEDICARE: OLIVIA JENAI BURLISON

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	101YM0800X	Mental Health Counselor	6801104536	MI
2	390200000X	Student in an Organized Health Care Education/Training Program
3	1041C0700X	Clinical Social Worker	6801110678	MI

General Provider Information

NPI Number	:	1235619222
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLIVIA JENAI BURLISON

Provider Business Mailing Address
First Line	:	3740 CHERYL DR
Second Line	:
City	:	COMMERCE TOWNSHIP
State	:	MI
Zip	:	48382-1719
Country	:	US
Telephone Number	:	734-353-6143
Fax Number	:

Provider Business Practice Location Address
First Line	:	2300 HAGGERTY RD STE 2160
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48323-2192
Country	:	US
Telephone Number	:	248-859-2457
Fax Number	:

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

Provider Enumeration Date	:	08/19/2018
Last Update Date	:	12/19/2023

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Directions to “ OLIVIA JENAI BURLISON ” Practice Location

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