Provider Demographics
NPI:1285332361
Name:OLIVO, DIANA
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:OLIVO
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 1:107 FIELDS AVE
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30721-3264
Mailing Address - Country:US
Mailing Address - Phone:706-218-8977
Mailing Address - Fax:
Practice Address - Street 1:107 FIELDS AVE
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30721-3264
Practice Address - Country:US
Practice Address - Phone:706-218-8977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-20
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0005939604Medicaid