Provider Demographics
NPI:1275828865
Name:THE OLIVIA CENTER FOR DEVELOPMENTAL DISABILITIES, LLC
Entity Type:Organization
Organization Name:THE OLIVIA CENTER FOR DEVELOPMENTAL DISABILITIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TARA
Authorized Official - Middle Name:KELLY
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-899-5311
Mailing Address - Street 1:11050 CRABAPPLE RD
Mailing Address - Street 2:SUITE C-109
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-2489
Mailing Address - Country:US
Mailing Address - Phone:770-899-5311
Mailing Address - Fax:
Practice Address - Street 1:11050 CRABAPPLE RD
Practice Address - Street 2:SUITE C-109
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-2489
Practice Address - Country:US
Practice Address - Phone:770-899-5311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-13
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251C00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA662980423AMedicaid
GA662980423BMedicaid