Provider Demographics
NPI:1043616493
Name:OLSON, DOUGLAS (CMT, CMTPT)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:OLSON
Suffix:
Gender:M
Credentials:CMT, CMTPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1082 ALMADEN VILLAGE LN
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95120-3365
Mailing Address - Country:US
Mailing Address - Phone:408-406-1925
Mailing Address - Fax:
Practice Address - Street 1:1082 ALMADEN VILLAGE LN
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95120-3365
Practice Address - Country:US
Practice Address - Phone:408-406-1925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-12
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174H00000X
CA44401225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No174H00000XOther Service ProvidersHealth Educator