MEDICARE: CAROLE CRUSE-OLIVIERI PSY.D.

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	103TS0200X	School Psychologist	PPS-0600056	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0813000532	OTHER	VA	VA BOARD OF PSYCHOLOGY
2	PPS-0600056	OTHER	VA	COMMONWEALTH OF VA PUPIL PERSONNEL SERVICES LICENSE

General Provider Information

NPI Number	:	1669974978
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROLE CRUSE-OLIVIERI PSY.D.

Provider Business Mailing Address
First Line	:	43417 EDGEWATER ST
Second Line	:
City	:	CHANTILLY
State	:	VA
Zip	:	20152-1751
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	15301 LEE HWY
Second Line	:
City	:	CENTREVILLE
State	:	VA
Zip	:	20121-2126
Country	:	US
Telephone Number	:	703-456-2222
Fax Number	:

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

Provider Enumeration Date	:	03/02/2018
Last Update Date	:	03/02/2018

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