Provider Demographics
NPI:1497807127
Name:OLIVE, MICHELLE (PT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:OLIVE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 CURTIS RD
Mailing Address - Street 2:
Mailing Address - City:ENOLA
Mailing Address - State:AR
Mailing Address - Zip Code:72047-8238
Mailing Address - Country:US
Mailing Address - Phone:501-269-4117
Mailing Address - Fax:
Practice Address - Street 1:2915 DAVE WARD DR
Practice Address - Street 2:SUITE 8
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-9310
Practice Address - Country:US
Practice Address - Phone:501-329-5459
Practice Address - Fax:501-325-1378
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT27572251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics