Provider Demographics
NPI:1407523764
Name:OLIVE & OAK WELLNESS LLC
Entity Type:Organization
Organization Name:OLIVE & OAK WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAIGE
Authorized Official - Middle Name:
Authorized Official - Last Name:FANOLIS
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:860-334-7093
Mailing Address - Street 1:360B QUEEN ST # 175
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-1871
Mailing Address - Country:US
Mailing Address - Phone:860-334-7093
Mailing Address - Fax:
Practice Address - Street 1:1492 FLANDERS RD
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-1604
Practice Address - Country:US
Practice Address - Phone:860-334-7093
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-25
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty