Healthcare Provider Details

I. General information

NPI: 1952662207
Provider Name (Legal Business Name): MICHAEL OLIVER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2012
Last Update Date: 06/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24823 PACIFIC HWY S STE 103
KENT WA
98032-5478
US

IV. Provider business mailing address

24823 PACIFIC HWY S STE 103
KENT WA
98032-5478
US

V. Phone/Fax

Practice location:
  • Phone: 253-681-0010
  • Fax: 253-681-0014
Mailing address:
  • Phone: 253-681-0010
  • Fax: 253-681-0014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCG 60261470
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: