Provider Demographics
NPI:1003667338
Name:BOUGHTON, OLIVIA R (LMT)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:R
Last Name:BOUGHTON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 BOCK ST
Mailing Address - Street 2:
Mailing Address - City:GORDONSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22942-9177
Mailing Address - Country:US
Mailing Address - Phone:401-862-2837
Mailing Address - Fax:
Practice Address - Street 1:767 MADISON RD STE 108
Practice Address - Street 2:
Practice Address - City:CULPEPER
Practice Address - State:VA
Practice Address - Zip Code:22701-3340
Practice Address - Country:US
Practice Address - Phone:401-862-2837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-27
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019019166225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist