Provider Demographics
NPI:1407154909
Name:OLSON, SAMANTHA DAISY (PTA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:DAISY
Last Name:OLSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 E 18TH ST
Mailing Address - Street 2:
Mailing Address - City:YANKTON
Mailing Address - State:SD
Mailing Address - Zip Code:57078-2415
Mailing Address - Country:US
Mailing Address - Phone:605-690-7269
Mailing Address - Fax:
Practice Address - Street 1:129 E CLAY ST
Practice Address - Street 2:
Practice Address - City:IRENE
Practice Address - State:SD
Practice Address - Zip Code:57037-2034
Practice Address - Country:US
Practice Address - Phone:605-263-3318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-07
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0313225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant