Provider Demographics
NPI:1508303454
Name:BOUSSAR, OLIVIA
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:BOUSSAR
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 1:3638 BEL PRE RD
Mailing Address - Street 2:APT 34
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20906-2609
Mailing Address - Country:US
Mailing Address - Phone:240-938-6343
Mailing Address - Fax:
Practice Address - Street 1:3638 BEL PRE RD
Practice Address - Street 2:APT 34
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20906-2609
Practice Address - Country:US
Practice Address - Phone:240-938-6343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-30
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X, 171M00000X
DCHHA12638374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251S00000XAgenciesCommunity/Behavioral Health
No374U00000XNursing Service Related ProvidersHome Health Aide