Provider Demographics
NPI:1578524187
Name:OLSON, ROBERTA LYNN (MS CCC SLP)
Entity Type:Individual
Prefix:MS
First Name:ROBERTA
Middle Name:LYNN
Last Name:OLSON
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2523 14 3/4 AVE
Mailing Address - Street 2:
Mailing Address - City:RICE LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54868
Mailing Address - Country:US
Mailing Address - Phone:715-859-6670
Mailing Address - Fax:715-859-6669
Practice Address - Street 1:900 COLLEGE AVE W
Practice Address - Street 2:
Practice Address - City:LADYSMITH
Practice Address - State:WI
Practice Address - Zip Code:54848
Practice Address - Country:US
Practice Address - Phone:715-532-5561
Practice Address - Fax:715-532-5146
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2165154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42798800Medicaid