Provider Demographics
NPI:1144573411
Name:OLIVA, MARY ELLEN (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELLEN
Last Name:OLIVA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 LONGVIEW RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:CT
Mailing Address - Zip Code:06468-1702
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13 PARK LAWN DR
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:CT
Practice Address - Zip Code:06801-1043
Practice Address - Country:US
Practice Address - Phone:203-830-4180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-23
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1740382803314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility