Provider Demographics
NPI:1558303396
Name:OLSEN, MARY MICHAEL (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MICHAEL
Last Name:OLSEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 E BOGARD RD
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7108
Mailing Address - Country:US
Mailing Address - Phone:907-357-2578
Mailing Address - Fax:907-357-2529
Practice Address - Street 1:401 E BOGARD RD
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7108
Practice Address - Country:US
Practice Address - Phone:907-357-2578
Practice Address - Fax:907-357-2529
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK992225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist