Provider Demographics
NPI:1891163952
Name:OLIVE, DEMETRICE
Entity Type:Individual
Prefix:
First Name:DEMETRICE
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 1:2102 GRAND BROOK CIR APT 1232A
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32810-6911
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2102 GRAND BROOK CIR APT 1232A
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32810-6911
Practice Address - Country:US
Practice Address - Phone:407-461-9017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-07
Last Update Date:2015-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL29849225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL11052014Medicare PIN