Provider Demographics
NPI:1720686488
Name:BERRYESSA, OLIVIA (LMT)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:BERRYESSA
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 1:2621 PALOMA AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4772
Mailing Address - Country:US
Mailing Address - Phone:541-324-8006
Mailing Address - Fax:
Practice Address - Street 1:709 N PHOENIX RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-9488
Practice Address - Country:US
Practice Address - Phone:541-324-8006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-15
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR26099225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist