Provider Demographics
NPI:1821532086
Name:OLIVER, KIERSTIN
Entity Type:Individual
Prefix:
First Name:KIERSTIN
Middle Name:
Last Name:OLIVER
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 1:525 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-5457
Mailing Address - Country:US
Mailing Address - Phone:207-874-1045
Mailing Address - Fax:207-767-0995
Practice Address - Street 1:525 MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-5457
Practice Address - Country:US
Practice Address - Phone:207-874-1045
Practice Address - Fax:207-767-0995
Is Sole Proprietor?:No
Enumeration Date:2016-12-07
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL4821101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor