Healthcare Provider Details

I. General information

NPI: 1942197629
Provider Name (Legal Business Name): OLIVIA OBRIEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2025
Last Update Date: 06/23/2025
Certification Date: 06/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4155 VETERANS HWY STE 5
RONKONKOMA NY
11779-6063
US

IV. Provider business mailing address

1363 CHURCH ST
BOHEMIA NY
11716-5013
US

V. Phone/Fax

Practice location:
  • Phone: 631-412-4800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number031789
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: