Provider Demographics
NPI:1609100874
Name:WILLISHENRY, OLIVIA MARIE (MA CCC SLP, MA CCC-A)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:MARIE
Last Name:WILLISHENRY
Suffix:
Gender:F
Credentials:MA CCC SLP, MA CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 SATURN BLVD # B361
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-4766
Mailing Address - Country:US
Mailing Address - Phone:818-488-4349
Mailing Address - Fax:
Practice Address - Street 1:555 SATURN BLVD
Practice Address - Street 2:SUITE 361
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92154-4766
Practice Address - Country:US
Practice Address - Phone:951-473-9570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-21
Last Update Date:2023-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU874231H00000X
235Z00000X
CASP5477235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASP5477OtherSPEECH PATHOLOGY LICENSE NUMBER