Provider Demographics
NPI:1922728039
Name:GROS, OLIVIA MARIE
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:MARIE
Last Name:GROS
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 1:929 RIDGEFIELD RD APT 5
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-2875
Mailing Address - Country:US
Mailing Address - Phone:985-413-5131
Mailing Address - Fax:
Practice Address - Street 1:420 N I-10 SERVICE RD W.
Practice Address - Street 2:
Practice Address - City:METARIE
Practice Address - State:LA
Practice Address - Zip Code:70006
Practice Address - Country:US
Practice Address - Phone:504-475-5303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-30
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician