Provider Demographics
NPI:1902564164
Name:ELLIS, OLIVIA
Entity Type:Individual
Prefix:MRS
First Name:OLIVIA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:OLIVIA
Other - Middle Name:
Other - Last Name:SWEARINGEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:273 BIG STATION CAMP BLVD APT 6103
Mailing Address - Street 2:
Mailing Address - City:GALLATIN
Mailing Address - State:TN
Mailing Address - Zip Code:37066-8484
Mailing Address - Country:US
Mailing Address - Phone:615-970-8852
Mailing Address - Fax:
Practice Address - Street 1:1535 N MOUNT JULIET RD
Practice Address - Street 2:
Practice Address - City:MOUNT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-3315
Practice Address - Country:US
Practice Address - Phone:615-560-6622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-06
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician