Provider Demographics
NPI:1508905498
Name:OLIVER, THEODORE (LCSW)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:OLIVER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 BROADWAY
Mailing Address - Street 2:PO BOX 708
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-4200
Mailing Address - Country:US
Mailing Address - Phone:573-221-2120
Mailing Address - Fax:
Practice Address - Street 1:917 BROADWAY
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-4200
Practice Address - Country:US
Practice Address - Phone:573-221-2120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0048301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical