Provider Demographics
NPI:1760823223
Name:OLIVE, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:OLIVE
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 1:550 E STRAWBRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-4905
Mailing Address - Country:US
Mailing Address - Phone:321-750-1234
Mailing Address - Fax:
Practice Address - Street 1:550 E STRAWBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-4905
Practice Address - Country:US
Practice Address - Phone:321-750-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-12
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health