Provider Demographics
NPI:1811597420
Name:OLIVE BRANCH THERAPY AND FAMILY SERVICES LLC
Entity Type:Organization
Organization Name:OLIVE BRANCH THERAPY AND FAMILY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:PRISCILLA
Authorized Official - Middle Name:C
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:414-429-8603
Mailing Address - Street 1:3625 N 58TH BLVD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-2848
Mailing Address - Country:US
Mailing Address - Phone:414-429-8603
Mailing Address - Fax:
Practice Address - Street 1:4369 S HOWELL AVE STE 305
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53207-5055
Practice Address - Country:US
Practice Address - Phone:414-465-8317
Practice Address - Fax:141-443-3445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-01
Last Update Date:2020-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty