Provider Demographics
NPI:1679036727
Name:SAN DIEGO, OLIVIA SIMONE (LMT)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:SIMONE
Last Name:SAN DIEGO
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 1:3018 22ND AVE W
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98199-2919
Mailing Address - Country:US
Mailing Address - Phone:206-551-0061
Mailing Address - Fax:
Practice Address - Street 1:160 ROY ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109-4162
Practice Address - Country:US
Practice Address - Phone:206-453-4137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-06
Last Update Date:2019-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60926512225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist