Provider Demographics
NPI:1447748546
Name:CROUSE TELLEZ, OLIVIA RENEE
Entity Type:Individual
Prefix:MS
First Name:OLIVIA
Middle Name:RENEE
Last Name:CROUSE TELLEZ
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 1:14301 EWING AVE S
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55306-4885
Mailing Address - Country:US
Mailing Address - Phone:592-746-5350
Mailing Address - Fax:
Practice Address - Street 1:14301 EWING AVE S
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55306-4885
Practice Address - Country:US
Practice Address - Phone:952-746-5350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-25
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician