MEDICARE: OLIVIA BANVILLE LCMHC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	17699	NC

General Provider Information

NPI Number	:	1417656851
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLIVIA BANVILLE LCMHC

Provider Business Mailing Address
First Line	:	5509 CREEDMOOR RD
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27612-6312
Country	:	US
Telephone Number	:	919-573-6538
Fax Number	:	919-573-6555

Provider Business Practice Location Address
First Line	:	3301 HAMMOND RD
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27603-3559
Country	:	US
Telephone Number	:	919-255-7237
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/24/2023
Last Update Date	:	03/18/2026

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