=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093520645
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OLIVIA BOOTH LMBT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2025
-----------------------------------------------------
Last Update Date | 02/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3598 HIGHWAY 11 STE 216
-----------------------------------------------------
City | TRAVELERS REST
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29690-3502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-610-2006
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 209 HIGHLAND DR
-----------------------------------------------------
City | GREER
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29651-1121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 10406
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------