Provider Demographics
NPI:1730124157
Name:OLIVE BRANCH COUNSELING ASSOCIATES, INC.
Entity Type:Organization
Organization Name:OLIVE BRANCH COUNSELING ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LOUELLA
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:DEVRIES
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:708-687-3479
Mailing Address - Street 1:15601 CICERO AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:OAK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60452-3635
Mailing Address - Country:US
Mailing Address - Phone:708-687-3479
Mailing Address - Fax:708-687-3480
Practice Address - Street 1:15601 CICERO AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:OAK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60452-3635
Practice Address - Country:US
Practice Address - Phone:708-687-3479
Practice Address - Fax:708-687-3480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL630260Medicare ID - Type Unspecified