MEDICARE: OLIVE TREE THERAPY & WELLNESS, LLC

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	261QM0855X	Adolescent and Children Mental Health Clinic/Center
2	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1558127365
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OLIVE TREE THERAPY & WELLNESS, LLC

Provider Business Mailing Address
First Line	:	107 ENTERPRISE PATH STE 300
Second Line	:
City	:	HIRAM
State	:	GA
Zip	:	30141-2690
Country	:	US
Telephone Number	:	678-361-5369
Fax Number	:

Provider Business Practice Location Address
First Line	:	107 ENTERPRISE PATH STE 300
Second Line	:
City	:	HIRAM
State	:	GA
Zip	:	30141-2690
Country	:	US
Telephone Number	:	678-361-5369
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ PSYCHOTHERAPIST
Name	:	MENYUAN JORDAN
Credential	:	LCSW
Telephone Number	:	678-361-5369

Provider Enumeration Date	:	02/28/2024
Last Update Date	:	04/23/2024

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