Provider Demographics
NPI:1093797771
Name:OLSSON NOONAN, LENA (PT)
Entity Type:Individual
Prefix:
First Name:LENA
Middle Name:
Last Name:OLSSON NOONAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LENA
Other - Middle Name:
Other - Last Name:OLSSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:19 SHEPARD ST
Mailing Address - Street 2:# 22
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-1728
Mailing Address - Country:US
Mailing Address - Phone:617-868-3145
Mailing Address - Fax:617-643-4015
Practice Address - Street 1:5 WHITTIER PL
Practice Address - Street 2:SUITE 101
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-1428
Practice Address - Country:US
Practice Address - Phone:617-512-6856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-17
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1524225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA70010000Y65126OtherBCBS PRODUCTS INDEMNITY, PPA, HMO BLUE, MEDICARE ADVANTAGE HMO AND PPO PLANS
MA0342645Medicaid
MA468019OtherTUFTS PPO OUT OF NETWORK
MA0342645Medicaid