Provider Demographics
NPI:1538820717
Name:WOODMAN, OLIVIA RACHEL
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:RACHEL
Last Name:WOODMAN
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 1:63 BLUE FESCUE WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29209-5148
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5315 FAIRFIELD ROAD
Practice Address - Street 2:APARTMENT 612
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203
Practice Address - Country:US
Practice Address - Phone:803-569-0597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCBACB655503106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty