Healthcare Provider Details

I. General information

NPI: 1912666702
Provider Name (Legal Business Name): HEIDI OLIVIER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2021
Last Update Date: 12/09/2021
Certification Date: 12/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 CORINTH AVE
BROUSSARD LA
70518-7417
US

IV. Provider business mailing address

109 CORINTH AVE
BROUSSARD LA
70518-7417
US

V. Phone/Fax

Practice location:
  • Phone: 337-849-0955
  • Fax:
Mailing address:
  • Phone: 337-849-0955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number16079
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number16079
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number16079
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: