MEDICARE: DR. OLIVIA LYNN CAROLLO PSYD

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	103TC0700X	Clinical Psychologist	071.009421	IL

General Provider Information

NPI Number	:	1679017735
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. OLIVIA LYNN CAROLLO PSYD

Provider Business Mailing Address
First Line	:	4851 N CLAREMONT AVE UNIT 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-1909
Country	:	US
Telephone Number	:	727-480-9038
Fax Number	:

Provider Business Practice Location Address
First Line	:	4527 N RAVENSWOOD AVE UNIT 105
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-5201
Country	:	US
Telephone Number	:	312-764-1244
Fax Number	:	312-586-8089

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

Provider Enumeration Date	:	12/08/2016
Last Update Date	:	02/09/2023

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