Provider Demographics
NPI:1669974978
Name:CRUSE-OLIVIERI, CAROLE (PSYD)
Entity type:Individual
Prefix:
First Name:CAROLE
Middle Name:
Last Name:CRUSE-OLIVIERI
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43417 EDGEWATER ST
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20152-1751
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15301 LEE HWY
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121-2126
Practice Address - Country:US
Practice Address - Phone:703-456-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-02
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAPPS-0600056103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0813000532OtherVA BOARD OF PSYCHOLOGY
VAPPS-0600056OtherCOMMONWEALTH OF VA PUPIL PERSONNEL SERVICES LICENSE