=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528625092
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OLIVIA PETERSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2019
-----------------------------------------------------
Last Update Date | 07/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 150 E WILSON BRIDGE RD STE 220
-----------------------------------------------------
City | WORTHINGTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43085-6302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-636-1413
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 41 N COLUMBUS ST
-----------------------------------------------------
City | SUNBURY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43074-9221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-560-5210
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | C.2103086-TRNE
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | E.2404502
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------