Provider Demographics
NPI:1700694650
Name:RAFFERTY, OLIVIA JOLENE (LMT)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:JOLENE
Last Name:RAFFERTY
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 1:5310 26TH ST W UNIT 903
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34207-3048
Mailing Address - Country:US
Mailing Address - Phone:941-299-4813
Mailing Address - Fax:
Practice Address - Street 1:5310 26TH ST W UNIT 903
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34207-3048
Practice Address - Country:US
Practice Address - Phone:941-299-4813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-24
Last Update Date:2024-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA105484225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist