Provider Demographics
NPI:1952662207
Name:OLIVER, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:OLIVER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24823 PACIFIC HWY S STE 103
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98032-5478
Mailing Address - Country:US
Mailing Address - Phone:253-681-0010
Mailing Address - Fax:253-681-0014
Practice Address - Street 1:24823 PACIFIC HWY S STE 103
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-5478
Practice Address - Country:US
Practice Address - Phone:253-681-0010
Practice Address - Fax:253-681-0014
Is Sole Proprietor?:No
Enumeration Date:2012-06-04
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG 60261470101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA12345OtherDSHS