Provider Demographics
NPI:1205378783
Name:PELTS, OLIVIA LEIGH (MA)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:LEIGH
Last Name:PELTS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 13TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST. PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713
Mailing Address - Country:US
Mailing Address - Phone:321-348-7681
Mailing Address - Fax:
Practice Address - Street 1:1900 13TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-5738
Practice Address - Country:US
Practice Address - Phone:321-348-7681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-15
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX71322101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health