Provider Demographics
NPI:1285136622
Name:OLIVE BRANCH AUTISM CLINIC AND THERAPY SERVICES LLC
Entity type:Organization
Organization Name:OLIVE BRANCH AUTISM CLINIC AND THERAPY SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:SHAWNA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:NICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:770-630-6753
Mailing Address - Street 1:2526 KINSGATE FOREST DR
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494-1898
Mailing Address - Country:US
Mailing Address - Phone:770-630-6753
Mailing Address - Fax:832-553-7719
Practice Address - Street 1:2526 KINSGATE FOREST DR
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77494-1898
Practice Address - Country:US
Practice Address - Phone:832-557-0579
Practice Address - Fax:832-553-7719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-01
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX108185261QH0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech