Provider Demographics
NPI:1851960868
Name:PRINZ, OLIVIA GRACE FLEMING
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:GRACE FLEMING
Last Name:PRINZ
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 1:1380 LEAD HILL BLVD STE 160
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-2998
Mailing Address - Country:US
Mailing Address - Phone:916-740-6424
Mailing Address - Fax:
Practice Address - Street 1:1380 LEAD HILL BLVD STE 160
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-2998
Practice Address - Country:US
Practice Address - Phone:916-740-6424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-23
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CA137290106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA137290OtherBBS