Provider Demographics
NPI:1053992123
Name:WHITE BROCK, OLIVIA KATHRYN (MS, NCC, LPC, LMHC)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:KATHRYN
Last Name:WHITE BROCK
Suffix:
Gender:F
Credentials:MS, NCC, LPC, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:287 LORTON AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-4203
Mailing Address - Country:US
Mailing Address - Phone:877-505-7147
Mailing Address - Fax:
Practice Address - Street 1:287 LORTON AVE
Practice Address - Street 2:
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-4203
Practice Address - Country:US
Practice Address - Phone:877-505-7147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-19
Last Update Date:2022-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1099274101YM0800X
WALH61227686101YM0800X
PAPC013147101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health