Healthcare Provider Details

I. General information

NPI: 1386329092
Provider Name (Legal Business Name): OLIVIA MARIE ROSE LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2023
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3120 N OAK STREET EXT STE B
VALDOSTA GA
31602-5910
US

IV. Provider business mailing address

3120 N OAK STREET EXT STE C
VALDOSTA GA
31602-5910
US

V. Phone/Fax

Practice location:
  • Phone: 229-671-6170
  • Fax: 229-671-6761
Mailing address:
  • Phone: 229-671-6170
  • Fax: 229-671-6761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT002447
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: