Provider Demographics
NPI:1316043219
Name:OLSON, VICTORIA MARY (COTA)
Entity Type:Individual
Prefix:MS
First Name:VICTORIA
Middle Name:MARY
Last Name:OLSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14909 56TH ST N
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-6704
Mailing Address - Country:US
Mailing Address - Phone:651-439-0909
Mailing Address - Fax:
Practice Address - Street 1:2705 ENLOE ST
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-8173
Practice Address - Country:US
Practice Address - Phone:715-386-2128
Practice Address - Fax:715-386-6119
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1081224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4774300Medicaid