Healthcare Provider Details

I. General information

NPI: 1669053153
Provider Name (Legal Business Name): OLIVE BRANCH COUNSELING SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2021
Last Update Date: 04/16/2021
Certification Date: 04/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 WOODFORD AVENUE EXT APT 1
PLAINVILLE CT
06062-2561
US

IV. Provider business mailing address

75 WOODFORD AVENUE EXT APT 1
PLAINVILLE CT
06062-2561
US

V. Phone/Fax

Practice location:
  • Phone: 860-921-3417
  • Fax:
Mailing address:
  • Phone: 860-921-3417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: AMANDA AYERS
Title or Position: OWNER
Credential: LCSW
Phone: 860-921-3417