Provider Demographics
NPI:1386067213
Name:OLT, ROBERT EDWARD
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:EDWARD
Last Name:OLT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ROBERT
Other - Middle Name:
Other - Last Name:OLT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:588 S PLUM ST
Mailing Address - Street 2:
Mailing Address - City:HAVANA
Mailing Address - State:IL
Mailing Address - Zip Code:62644-1374
Mailing Address - Country:US
Mailing Address - Phone:309-253-7611
Mailing Address - Fax:
Practice Address - Street 1:588 S PLUM ST
Practice Address - Street 2:
Practice Address - City:HAVANA
Practice Address - State:IL
Practice Address - Zip Code:62644-1374
Practice Address - Country:US
Practice Address - Phone:309-253-7611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-29
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.008386103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical