Provider Demographics
NPI:1235995291
Name:JUSTICE, OLIVIA ROSE
Entity Type:Individual
Prefix:MISS
First Name:OLIVIA
Middle Name:ROSE
Last Name:JUSTICE
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 1:3514 CLAIRMONT ST
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503-6608
Mailing Address - Country:US
Mailing Address - Phone:810-282-4216
Mailing Address - Fax:
Practice Address - Street 1:210 TOWN CENTER DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-1774
Practice Address - Country:US
Practice Address - Phone:866-812-8896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202010054224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant