Provider Demographics
NPI:1467684324
Name:LIPSCOMB, OLIVIA (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:OLIVIA
Middle Name:
Last Name:LIPSCOMB
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 BAYOU RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38701-7725
Mailing Address - Country:US
Mailing Address - Phone:601-906-3902
Mailing Address - Fax:
Practice Address - Street 1:124 BAYOU RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-7725
Practice Address - Country:US
Practice Address - Phone:601-906-3902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-11
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARO-T0914174400000X
MSOT2398225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR177891721Medicaid