Provider Demographics
NPI:1962278069
Name:OLIVE TREE 1 CARE OF MARYLAND
Entity type:Organization
Organization Name:OLIVE TREE 1 CARE OF MARYLAND
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:JAVON
Authorized Official - Middle Name:CORY
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:202-340-1953
Mailing Address - Street 1:8418 THORNBERRY DR E
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-5061
Mailing Address - Country:US
Mailing Address - Phone:202-340-1953
Mailing Address - Fax:
Practice Address - Street 1:418 SHEPHERD ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-5944
Practice Address - Country:US
Practice Address - Phone:202-340-1953
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OLIVE TREE 1 CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-11-29
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC021983047Medicaid