Provider Demographics
NPI:1104304336
Name:KERN, OLIVIA VICTORIA (OT)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:VICTORIA
Last Name:KERN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:OLIVIA
Other - Middle Name:VISTORIA
Other - Last Name:LUCUIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2425 E SOUTHLAKE BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6675
Mailing Address - Country:US
Mailing Address - Phone:817-442-0222
Mailing Address - Fax:817-442-0223
Practice Address - Street 1:2425 E SOUTHLAKE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6675
Practice Address - Country:US
Practice Address - Phone:817-442-0222
Practice Address - Fax:817-442-0223
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118335225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist