Provider Demographics
NPI:1255740486
Name:BLUE, OLYTHIA
Entity type:Individual
Prefix:
First Name:OLYTHIA
Middle Name:
Last Name:BLUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:OLYTHIA
Other - Middle Name:TAMARA
Other - Last Name:BLUE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CIT
Mailing Address - Street 1:3430 PARK HEIGHTS AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-7841
Mailing Address - Country:US
Mailing Address - Phone:410-900-4599
Mailing Address - Fax:
Practice Address - Street 1:14 S BROADWAY
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21231-1712
Practice Address - Country:US
Practice Address - Phone:410-276-1773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-13
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDADT820101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)