Provider Demographics
NPI:1316122930
Name:OLIVE, BRANDON R (PHD)
Entity type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:R
Last Name:OLIVE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:338 DOUGLAS DR
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41501-6820
Mailing Address - Country:US
Mailing Address - Phone:859-640-3870
Mailing Address - Fax:
Practice Address - Street 1:338 DOUGLAS DR
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-6820
Practice Address - Country:US
Practice Address - Phone:859-640-3870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-02
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-1229103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1216863OtherCHA HEALTH