Provider Demographics
NPI:1962697458
Name:OLAIVAR, SHERYL ROSE (OT)
Entity type:Individual
Prefix:
First Name:SHERYL
Middle Name:ROSE
Last Name:OLAIVAR
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1182
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:MS
Mailing Address - Zip Code:39560-1182
Mailing Address - Country:US
Mailing Address - Phone:228-669-0643
Mailing Address - Fax:
Practice Address - Street 1:15476 DEDEAUX RD STE A
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-2637
Practice Address - Country:US
Practice Address - Phone:228-539-3232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-08
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT0806225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1912033291OtherGROUP NPI
MS09015385Medicaid
MS1912033291OtherGROUP NPI