Provider Demographics
NPI:1336654367
Name:BRANSCOMB-BURGESS, OLIVIA (LMSW)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:BRANSCOMB-BURGESS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 COLLIER ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-2911
Mailing Address - Country:US
Mailing Address - Phone:512-472-4357
Mailing Address - Fax:
Practice Address - Street 1:5015 S IH 35 STE 200
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78744-2714
Practice Address - Country:US
Practice Address - Phone:512-703-3234
Practice Address - Fax:512-703-1390
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-13
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64316104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker