Provider Demographics
NPI:1508489733
Name:MANDICH, OLIVIA DANIELLE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:OLIVIA
Middle Name:DANIELLE
Last Name:MANDICH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:OLIVIA
Other - Middle Name:DANIELLE
Other - Last Name:RUNYON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:107 KOONTZ AVE
Mailing Address - Street 2:
Mailing Address - City:CLENDENIN
Mailing Address - State:WV
Mailing Address - Zip Code:25045-9578
Mailing Address - Country:US
Mailing Address - Phone:304-548-7272
Mailing Address - Fax:
Practice Address - Street 1:107 KOONTZ AVE
Practice Address - Street 2:
Practice Address - City:CLENDENIN
Practice Address - State:WV
Practice Address - Zip Code:25045-9578
Practice Address - Country:US
Practice Address - Phone:304-734-2040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-21
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WV1320103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program