Basic Information
| Provider Information | |||||||||
| NPI: | 1255918348 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OCTAVIUS | ||||||||
| FirstName: | LOVELY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6550 DELILAH RD STE 301 | ||||||||
| Address2: | |||||||||
| City: | EGG HARBOR TOWNSHIP | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 082345102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6092728580 | ||||||||
| FaxNumber: | 6093832868 | ||||||||
| Practice Location | |||||||||
| Address1: | 6010 BLACK HORSE PIKE | ||||||||
| Address2: | |||||||||
| City: | EGG HARBOR TOWNSHIP | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 082349752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6092720909 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2021 | ||||||||
| LastUpdateDate: | 03/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.