Provider Demographics
NPI:1578817060
Name:IRELAND, OLIVIA TAI (CSP,LMP)
Entity Type:Individual
Prefix:MS
First Name:OLIVIA
Middle Name:TAI
Last Name:IRELAND
Suffix:
Gender:F
Credentials:CSP,LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1622 FRANKLIN ST SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-2308
Mailing Address - Country:US
Mailing Address - Phone:360-789-8254
Mailing Address - Fax:
Practice Address - Street 1:219 LEGION WAY SW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-1297
Practice Address - Country:US
Practice Address - Phone:360-789-8254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-05
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60298302225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist