Provider Demographics
NPI:1558903443
Name:GORNEAU, OLIVIA ROSE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:OLIVIA
Middle Name:ROSE
Last Name:GORNEAU
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MISS
Other - First Name:OLIVIA
Other - Middle Name:ROSE
Other - Last Name:LACHANCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:162 WEST ROAD
Mailing Address - Street 2:
Mailing Address - City:WEST GARDINER
Mailing Address - State:ME
Mailing Address - Zip Code:04345
Mailing Address - Country:US
Mailing Address - Phone:207-724-2017
Mailing Address - Fax:
Practice Address - Street 1:128 SECOND STREET
Practice Address - Street 2:
Practice Address - City:HALLOWELL
Practice Address - State:ME
Practice Address - Zip Code:04347
Practice Address - Country:US
Practice Address - Phone:207-623-9355
Practice Address - Fax:207-623-9354
Is Sole Proprietor?:No
Enumeration Date:2019-10-11
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT5417225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist