Provider Demographics
NPI:1588146690
Name:MORRIS, OCTAVIA M
Entity type:Individual
Prefix:
First Name:OCTAVIA
Middle Name:M
Last Name:MORRIS
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 1:5287 BERMUDA LN
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48505-1066
Mailing Address - Country:US
Mailing Address - Phone:328-354-8438
Mailing Address - Fax:
Practice Address - Street 1:5287 BERMUDA LN
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48505-1066
Practice Address - Country:US
Practice Address - Phone:328-354-8438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI4703128867164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician