Provider Demographics
NPI:1093323719
Name:THOMPSON, OLIVIA MICHELLE
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:MICHELLE
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4529 W HARBOR RD
Mailing Address - Street 2:
Mailing Address - City:PORT CLINTON
Mailing Address - State:OH
Mailing Address - Zip Code:43452-9026
Mailing Address - Country:US
Mailing Address - Phone:419-389-2411
Mailing Address - Fax:
Practice Address - Street 1:5726 SOUTHWYCK BLVD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-1559
Practice Address - Country:US
Practice Address - Phone:419-708-0441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-20
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator