Provider Demographics
NPI:1932724325
Name:VAUGHN, OLIVIA
Entity Type:Individual
Prefix:MS
First Name:OLIVIA
Middle Name:
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:OLIVIA
Other - Middle Name:
Other - Last Name:SILVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT MEDICAL CE
Mailing Address - Street 1:4388 W VICKERY BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-6339
Mailing Address - Country:US
Mailing Address - Phone:817-796-6765
Mailing Address - Fax:
Practice Address - Street 1:4388 W VICKERY BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-6339
Practice Address - Country:US
Practice Address - Phone:817-769-9765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-10
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX126261225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty