Provider Demographics
NPI:1528625092
Name:PETERSON, OLIVIA
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:PETERSON
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 1:41 N COLUMBUS ST
Mailing Address - Street 2:
Mailing Address - City:SUNBURY
Mailing Address - State:OH
Mailing Address - Zip Code:43074-9221
Mailing Address - Country:US
Mailing Address - Phone:419-560-5210
Mailing Address - Fax:
Practice Address - Street 1:150 E WILSON BRIDGE RD STE 220
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43085-6302
Practice Address - Country:US
Practice Address - Phone:614-636-1413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-21
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2103086-TRNE101YM0800X
OHE.2404502101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health