Provider Demographics
NPI:1366851107
Name:OLSON, MACKENZIE (DPT)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:OLSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1365 CLIFTON RD NE STE 2218
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322-2490
Mailing Address - Country:US
Mailing Address - Phone:404-712-1620
Mailing Address - Fax:
Practice Address - Street 1:1365 CLIFTON RD NE STE 2218
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-1013
Practice Address - Country:US
Practice Address - Phone:404-712-1620
Practice Address - Fax:404-712-4130
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-06
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0115892251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic