Provider Demographics
NPI:1558913087
Name:OLSON, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:OLSON
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 1:6205 WILLIAMSBURG WAY APT 217
Mailing Address - Street 2:
Mailing Address - City:DEFOREST
Mailing Address - State:WI
Mailing Address - Zip Code:53532-9123
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2815 NEW PINERY RD STE 1
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-9257
Practice Address - Country:US
Practice Address - Phone:608-745-6290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14167-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist