Healthcare Provider Details

I. General information

NPI: 1104755164
Provider Name (Legal Business Name): OLIVIA NICOLE TAYLOR LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2026
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 N 5TH ST
LEESVILLE LA
71446-4029
US

IV. Provider business mailing address

79 SPECKER ST
FORT LEONARD WOOD MO
65473-1241
US

V. Phone/Fax

Practice location:
  • Phone: 337-423-5225
  • Fax:
Mailing address:
  • Phone: 419-979-9517
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberLA10496
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: