Provider Demographics
NPI:1407402589
Name:OLIVER, MADELINE
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:OLIVER
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 1:6524 W 300 N
Mailing Address - Street 2:
Mailing Address - City:EARL PARK
Mailing Address - State:IN
Mailing Address - Zip Code:47942-8670
Mailing Address - Country:US
Mailing Address - Phone:804-840-0940
Mailing Address - Fax:
Practice Address - Street 1:200 FERRY ST STE B
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47901-1172
Practice Address - Country:US
Practice Address - Phone:317-782-5504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-14
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN85000429A106H00000X
IN35002256A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist