Provider Demographics
NPI:1578072724
Name:OLIVER, MARY ANN
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:OLIVER
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 1:1306 PADDOCK DR STE E100
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-4873
Mailing Address - Country:US
Mailing Address - Phone:919-790-7775
Mailing Address - Fax:919-790-9755
Practice Address - Street 1:1016 BROAD ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-4144
Practice Address - Country:US
Practice Address - Phone:919-286-6766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-20
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCSAC21548101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1568595510Medicaid