Provider Demographics
NPI:1720651037
Name:FUSTOS, OLIVIA G
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:G
Last Name:FUSTOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4835 ANNE LN
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:PA
Mailing Address - Zip Code:16148-6556
Mailing Address - Country:US
Mailing Address - Phone:724-699-1524
Mailing Address - Fax:
Practice Address - Street 1:430 FRANKLIN ST SE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-5715
Practice Address - Country:US
Practice Address - Phone:330-372-2200
Practice Address - Fax:330-372-2600
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-23
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2103246-TRNE101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health