Provider Demographics
NPI:1750962734
Name:BRACK, OLIVIA JANE
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:JANE
Last Name:BRACK
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 1:4949 COOLIDGE HWY
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-1026
Mailing Address - Country:US
Mailing Address - Phone:248-655-5660
Mailing Address - Fax:248-655-5974
Practice Address - Street 1:4949 COOLIDGE HWY
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-1026
Practice Address - Country:US
Practice Address - Phone:248-655-5660
Practice Address - Fax:248-655-5974
Is Sole Proprietor?:No
Enumeration Date:2021-04-20
Last Update Date:2025-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101009415235Z00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist