Provider Demographics
NPI:1457829079
Name:OLIVER, LERAY MARIE
Entity Type:Individual
Prefix:
First Name:LERAY
Middle Name:MARIE
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 1:7585 TOWNSHIP ROAD 331 SE
Mailing Address - Street 2:
Mailing Address - City:CORNING
Mailing Address - State:OH
Mailing Address - Zip Code:43730-9702
Mailing Address - Country:US
Mailing Address - Phone:740-347-9828
Mailing Address - Fax:
Practice Address - Street 1:213 E CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-3404
Practice Address - Country:US
Practice Address - Phone:740-326-9255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-13
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.171323101YA0400X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator