Provider Demographics
NPI:1144622564
Name:OLIVA, ANGELA
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:OLIVA
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 1:5732 113TH AVE
Mailing Address - Street 2:
Mailing Address - City:FENNVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49408-8513
Mailing Address - Country:US
Mailing Address - Phone:269-352-6377
Mailing Address - Fax:
Practice Address - Street 1:1022 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-3036
Practice Address - Country:US
Practice Address - Phone:269-926-0015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-17
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802086191101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)