Provider Demographics
NPI:1114524113
Name:KUTZBERGER, OLIVIA JEAN
Entity Type:Individual
Prefix:MRS
First Name:OLIVIA
Middle Name:JEAN
Last Name:KUTZBERGER
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 1:801 WATERWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-8182
Mailing Address - Country:US
Mailing Address - Phone:614-477-8740
Mailing Address - Fax:
Practice Address - Street 1:801 WATERWOOD WAY
Practice Address - Street 2:
Practice Address - City:SPRINGBORO
Practice Address - State:OH
Practice Address - Zip Code:45066-8182
Practice Address - Country:US
Practice Address - Phone:614-477-8740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-04
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OH2573232374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2573232Medicaid