Healthcare Provider Details

I. General information

NPI: 1740769942
Provider Name (Legal Business Name): TRACI W OLIVIER PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2018
Last Update Date: 05/19/2025
Certification Date: 05/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4611 BLUEBONNET BLVD STE B
BATON ROUGE LA
70809-9651
US

IV. Provider business mailing address

4611 BLUEBONNET BLVD STE B
BATON ROUGE LA
70809-9651
US

V. Phone/Fax

Practice location:
  • Phone: 225-926-7500
  • Fax: 225-924-0188
Mailing address:
  • Phone: 225-926-7500
  • Fax: 225-924-0188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number1462
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1462
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1462
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number1462
License Number StateLA
# 5
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number1462
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: