Provider Demographics
NPI:1376875153
Name:OLMSCHENK, SUSAN MAUREEN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MAUREEN
Last Name:OLMSCHENK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 PHYSICIANS DRIVE #106
Mailing Address - Street 2:
Mailing Address - City:SUPPLY
Mailing Address - State:NC
Mailing Address - Zip Code:28462
Mailing Address - Country:US
Mailing Address - Phone:910-755-6075
Mailing Address - Fax:910-755-6076
Practice Address - Street 1:58 PHYSICIANS DR STE 106
Practice Address - Street 2:
Practice Address - City:SUPPLY
Practice Address - State:NC
Practice Address - Zip Code:28462-4216
Practice Address - Country:US
Practice Address - Phone:910-755-6075
Practice Address - Fax:910-755-6076
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-04
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2898225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7301202Medicaid