=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003667338
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OLIVIA R. BOUGHTON LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2024
-----------------------------------------------------
Last Update Date | 03/27/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 767 MADISON RD STE 108
-----------------------------------------------------
City | CULPEPER
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22701-3340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-862-2837
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 307 BOCK ST
-----------------------------------------------------
City | GORDONSVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22942-9177
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-862-2837
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 0019019166
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------