1801340682 NPI number — OLIVIA RAE QUINN-HARRIS LCSW

Table of content: OLIVIA RAE QUINN-HARRIS LCSW (NPI 1801340682)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801340682 NPI number — OLIVIA RAE QUINN-HARRIS LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
QUINN-HARRIS
Provider First Name:
OLIVIA
Provider Middle Name:
RAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801340682
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/02/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
958 ROBERTS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DELTONA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32725-5761
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-738-1290
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
958 ROBERTS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DELTONA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32725-5761
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-738-1290
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/09/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 101155600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".