Provider Demographics
NPI:1669142519
Name:OLIVE BRANCH COUNSELING PLLC
Entity type:Organization
Organization Name:OLIVE BRANCH COUNSELING PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MENTAL HEALTH THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MADYSEN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:OSTROWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:815-307-4849
Mailing Address - Street 1:128 ELLSWORTH ST
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-4421
Mailing Address - Country:US
Mailing Address - Phone:815-307-4849
Mailing Address - Fax:
Practice Address - Street 1:128 ELLSWORTH ST
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-4421
Practice Address - Country:US
Practice Address - Phone:815-307-4849
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180010920OtherLCPC/OWNER