Provider Demographics
NPI:1558856294
Name:PRUIKSMA, OLIVIA ROSE (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:OLIVIA
Middle Name:ROSE
Last Name:PRUIKSMA
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
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Other - Suffix:
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Mailing Address - Street 1:15 MOHAWK LN
Mailing Address - Street 2:
Mailing Address - City:MANALAPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07726-4613
Mailing Address - Country:US
Mailing Address - Phone:732-239-0881
Mailing Address - Fax:
Practice Address - Street 1:521 GLENMERE AVE
Practice Address - Street 2:
Practice Address - City:NEPTUNE
Practice Address - State:NJ
Practice Address - Zip Code:07753-5610
Practice Address - Country:US
Practice Address - Phone:732-239-0881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-26
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00928300235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist