Provider Demographics
NPI:1114395449
Name:WACKETT, OLIVIA HELEN (LCSW-C)
Entity Type:Individual
Prefix:MS
First Name:OLIVIA
Middle Name:HELEN
Last Name:WACKETT
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:OLIVIA
Other - Middle Name:HELEN
Other - Last Name:MAGARELLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:505 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-5020
Mailing Address - Country:US
Mailing Address - Phone:410-749-1015
Mailing Address - Fax:410-749-0654
Practice Address - Street 1:1104 HEALTHWAY DR
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-4469
Practice Address - Country:US
Practice Address - Phone:410-219-5483
Practice Address - Fax:410-219-5486
Is Sole Proprietor?:No
Enumeration Date:2015-09-03
Last Update Date:2017-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD193231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD119591300Medicaid
MD119591300Medicaid
MDS118Medicare PIN