Provider Demographics
NPI:1639645518
Name:OLIVE BRANCH INC
Entity Type:Organization
Organization Name:OLIVE BRANCH INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOYCELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:317-500-4266
Mailing Address - Street 1:6509 CHERBOURG CIR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-6014
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4954 E 56TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-5773
Practice Address - Country:US
Practice Address - Phone:317-500-4266
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchoolGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1790917060Medicaid