Provider Demographics
NPI:1609146968
Name:OLMSTEAD, PETER SCOTT (ATC, PTA)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:SCOTT
Last Name:OLMSTEAD
Suffix:
Gender:M
Credentials:ATC, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-2543
Mailing Address - Country:US
Mailing Address - Phone:860-447-8558
Mailing Address - Fax:860-447-4552
Practice Address - Street 1:635 BROAD ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-2543
Practice Address - Country:US
Practice Address - Phone:860-447-8558
Practice Address - Fax:860-447-4552
Is Sole Proprietor?:No
Enumeration Date:2012-01-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000972225200000X
CT0001902255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer