MEDICARE: MICHELE B OLIVE LCSW, CSOTP

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	1041C0700X	Clinical Social Worker	0904006221	VA

General Provider Information

NPI Number	:	1629090444
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELE B OLIVE LCSW, CSOTP

Provider Business Mailing Address
First Line	:	472 POLARIS ST
Second Line	:	BLDG 586
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23461-1912
Country	:	US
Telephone Number	:	757-862-0047
Fax Number	:

Provider Business Practice Location Address
First Line	:	472 POLARIS ST
Second Line	:	BLDG 586
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23461-1912
Country	:	US
Telephone Number	:	757-862-0047
Fax Number	:

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

Provider Enumeration Date	:	07/24/2006
Last Update Date	:	05/19/2015

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