Healthcare Provider Details

I. General information

NPI: 1487256046
Provider Name (Legal Business Name): OLIVIA JENICE OLVERSON OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2020
Last Update Date: 11/09/2020
Certification Date: 11/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 FAIRVIEW RD
ELLENWOOD GA
30294-2704
US

IV. Provider business mailing address

110 VICTORIA DR
FAYETTEVILLE GA
30214-1163
US

V. Phone/Fax

Practice location:
  • Phone: 800-381-2195
  • Fax:
Mailing address:
  • Phone: 404-819-2799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: