Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0019X | Occupational Therapist - Physical Rehabilitation | 1201139845 | TN |
NPI | 1295318186 |
---|---|
Provider Name | Olivia Tyra |
First Address | Vienna, VA 22182-7506 |
Second Address | Vienna, VA 22182-7506 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/04/2021 |
Last Update Date | 29/04/2021 |