Healthcare Provider Details

I. General information

NPI: 1770130528
Provider Name (Legal Business Name): OLIVIA M MYLES LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2019
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21100 SOUTHGATE PARK BLVD
MAPLE HEIGHTS OH
44137-3004
US

IV. Provider business mailing address

7232 JUSTIN WAY
MENTOR OH
44060-4881
US

V. Phone/Fax

Practice location:
  • Phone: 440-578-8200
  • Fax:
Mailing address:
  • Phone: 440-578-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI.2507107
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: