Provider Demographics
NPI:1073148029
Name:OLSON, TRACEY LYNN (LMT)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:LYNN
Last Name:OLSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 486
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:WI
Mailing Address - Zip Code:54773-0486
Mailing Address - Country:US
Mailing Address - Phone:715-538-2333
Mailing Address - Fax:715-538-2429
Practice Address - Street 1:36321 MAIN ST
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:WI
Practice Address - Zip Code:54773-9186
Practice Address - Country:US
Practice Address - Phone:715-538-2333
Practice Address - Fax:715-538-2429
Is Sole Proprietor?:No
Enumeration Date:2020-03-10
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15007-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist