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General NPI Number Information
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NPI Number | 1639645518
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Entity Type | Organization
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Legal Business Name | OLIVE BRANCH INC
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Dates
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Enumeration Date | 10/18/2018
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Last Update Date | 08/18/2020
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Provider Practice Location Address
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Address Line | 4954 E 56TH ST
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City | INDIANAPOLIS
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State | IN
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Zip | 46220-5773
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Country | US
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Telephone | 317-500-4266
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Fax |
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Provider Business Mailing Address
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Address Line | 6509 CHERBOURG CIR
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City | INDIANAPOLIS
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State | IN
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Zip | 46220-6014
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER DIRECTOR
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Name | JOYCELYN WILSON
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Credential | LMHC
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Telephone | 317-500-4266
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1041S0200X
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Taxonomy Name | School Social Worker
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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