Provider Demographics
NPI:1942960695
Name:DORNBUSCH, OLIVIA G
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:G
Last Name:DORNBUSCH
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 1:407 KENWOOD AVE UNIT A
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45121-1357
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:407 KENWOOD AVE UNIT A
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:OH
Practice Address - Zip Code:45121-1357
Practice Address - Country:US
Practice Address - Phone:513-568-1287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-22
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH00000OtherLICENSURE BOARD