MEDICARE: OLIVIA WALLACE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	61161174	WA

General Provider Information

NPI Number	:	1639744436
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLIVIA WALLACE

Provider Business Mailing Address
First Line	:	820 OCEAN BEACH HWY STE 116
Second Line	:
City	:	LONGVIEW
State	:	WA
Zip	:	98632-4081
Country	:	US
Telephone Number	:	360-414-3220
Fax Number	:	360-353-5350

Provider Business Practice Location Address
First Line	:	820 OCEAN BEACH HWY STE 116
Second Line	:
City	:	LONGVIEW
State	:	WA
Zip	:	98632-4081
Country	:	US
Telephone Number	:	360-414-3220
Fax Number	:	360-353-5350

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2021
Last Update Date	:	05/24/2021

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Directions to “ OLIVIA WALLACE ” Practice Location

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