Provider Demographics
NPI:1932130341
Name:FAIRWEATHER, OLIVIA HELEN (MA)
Entity Type:Individual
Prefix:MS
First Name:OLIVIA
Middle Name:HELEN
Last Name:FAIRWEATHER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:CONSTANCE
Other - Middle Name:
Other - Last Name:BOXILL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:649 ROSE VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:NY
Mailing Address - Zip Code:12701-4346
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 COMMUNITY LANE
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NY
Practice Address - Zip Code:12754
Practice Address - Country:US
Practice Address - Phone:845-292-8770
Practice Address - Fax:845-292-4206
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY11083104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00398370Medicaid