Provider Demographics
NPI:1346060571
Name:CUNDIFF, OLIVIA RALEA
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:RALEA
Last Name:CUNDIFF
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 1:203 BROADVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27295-2013
Mailing Address - Country:US
Mailing Address - Phone:336-466-4136
Mailing Address - Fax:
Practice Address - Street 1:203 BROADVIEW AVE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:NC
Practice Address - Zip Code:27295-2013
Practice Address - Country:US
Practice Address - Phone:336-466-4136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-14
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA20657101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor