Provider Demographics
NPI:1710614938
Name:DEMICHELE, OLIVIA ROSE (DPT)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:ROSE
Last Name:DEMICHELE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15410 S MOUNTAIN PKWY STE 112
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-6691
Mailing Address - Country:US
Mailing Address - Phone:480-689-5534
Mailing Address - Fax:480-706-7997
Practice Address - Street 1:1702 S VAL VISTA DR STE 107
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-7386
Practice Address - Country:US
Practice Address - Phone:480-505-8140
Practice Address - Fax:480-706-7997
Is Sole Proprietor?:No
Enumeration Date:2022-08-07
Last Update Date:2022-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPT-32427225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist