Provider Demographics
NPI:1003846866
Name:OLSON, LIESL LYNN (PT)
Entity Type:Individual
Prefix:MRS
First Name:LIESL
Middle Name:LYNN
Last Name:OLSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4515 MARSHA SHARP FWY
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79407-2520
Mailing Address - Country:US
Mailing Address - Phone:806-744-7223
Mailing Address - Fax:806-740-3325
Practice Address - Street 1:3223 S LOOP 289
Practice Address - Street 2:STE 101
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79423-8312
Practice Address - Country:US
Practice Address - Phone:806-740-3342
Practice Address - Fax:806-740-3325
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1063550225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX168331001Medicaid
TX83686EMedicare ID - Type Unspecified