Provider Demographics
NPI:1194312454
Name:OLIVE BRANCH COUNSELING SERVICES LLC
Entity type:Organization
Organization Name:OLIVE BRANCH COUNSELING SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:POLANCO
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:443-331-5959
Mailing Address - Street 1:6805 BARNETT RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21239-1215
Mailing Address - Country:US
Mailing Address - Phone:443-331-5949
Mailing Address - Fax:
Practice Address - Street 1:6805 BARNETT RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21239-1215
Practice Address - Country:US
Practice Address - Phone:443-331-5949
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-21
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health