Provider Demographics
NPI:1053030999
Name:DECKERT, OLIVIA LYNN
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:LYNN
Last Name:DECKERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11038 HIGHWAY 707
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-9702
Mailing Address - Country:US
Mailing Address - Phone:843-215-2151
Mailing Address - Fax:843-492-5113
Practice Address - Street 1:11038 HIGHWAY 707
Practice Address - Street 2:
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576-9702
Practice Address - Country:US
Practice Address - Phone:843-215-2151
Practice Address - Fax:843-492-5113
Is Sole Proprietor?:No
Enumeration Date:2022-08-24
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12745225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist