Provider Demographics
NPI:1295318186
Name:TYRA, OLIVIA
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:TYRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8607 WESTWOOD CENTER DR STE 7
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-7506
Mailing Address - Country:US
Mailing Address - Phone:703-313-1930
Mailing Address - Fax:
Practice Address - Street 1:8607 WESTWOOD CENTER DR STE 7
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-7506
Practice Address - Country:US
Practice Address - Phone:703-313-1930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-29
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1201139845225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation