Provider Demographics
NPI:1902468606
Name:REA, OLIVIA DAISY LOUISE (ATC)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:DAISY LOUISE
Last Name:REA
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6620 NW HICKORY CT
Mailing Address - Street 2:
Mailing Address - City:PARKVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64152-8723
Mailing Address - Country:US
Mailing Address - Phone:816-521-9914
Mailing Address - Fax:
Practice Address - Street 1:6620 NW HICKORY CT
Practice Address - Street 2:
Practice Address - City:PARKVILLE
Practice Address - State:MO
Practice Address - Zip Code:64152-8723
Practice Address - Country:US
Practice Address - Phone:816-521-9914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-02
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20000290622255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer