Provider Demographics
NPI:1487227138
Name:KING DEBERRY, OLIVIA CHONTE
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:CHONTE
Last Name:KING DEBERRY
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 1:2103 ANSLEY PARK LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-8693
Mailing Address - Country:US
Mailing Address - Phone:901-240-2955
Mailing Address - Fax:
Practice Address - Street 1:2103 ANSLEY PARK LN
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-8693
Practice Address - Country:US
Practice Address - Phone:901-240-2955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-21
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
123OtherOTHER