Provider Demographics
NPI:1033468962
Name:OLSEN, KENNETH ROBERT (PTA)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:ROBERT
Last Name:OLSEN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2916 L. HUNTINGTON RD.
Mailing Address - Street 2:
Mailing Address - City:FT. WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46809-2619
Mailing Address - Country:US
Mailing Address - Phone:260-242-3290
Mailing Address - Fax:
Practice Address - Street 1:1802 DOWLING ST
Practice Address - Street 2:
Practice Address - City:KENDALLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46755
Practice Address - Country:US
Practice Address - Phone:260-347-4374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-06
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06003749A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant