MEDICARE: OLIVIA GRACE FLEMING PRINZ

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	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	106H00000X	Marriage & Family Therapist	137290	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	137290	OTHER	CA	BBS

General Provider Information

NPI Number	:	1851960868
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLIVIA GRACE FLEMING PRINZ

Provider Business Mailing Address
First Line	:	1380 LEAD HILL BLVD STE 160
Second Line	:
City	:	ROSEVILLE
State	:	CA
Zip	:	95661-2998
Country	:	US
Telephone Number	:	916-740-6424
Fax Number	:

Provider Business Practice Location Address
First Line	:	1380 LEAD HILL BLVD STE 160
Second Line	:
City	:	ROSEVILLE
State	:	CA
Zip	:	95661-2998
Country	:	US
Telephone Number	:	916-740-6424
Fax Number	:

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

Provider Enumeration Date	:	06/23/2021
Last Update Date	:	02/09/2023

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