Provider Demographics
NPI:1619174471
Name:OLMSTEAD, PANDY M
Entity Type:Individual
Prefix:MS
First Name:PANDY
Middle Name:M
Last Name:OLMSTEAD
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:PANDY
Other - Middle Name:M
Other - Last Name:OLMSTEAD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MASSAGE THERAPIST
Mailing Address - Street 1:736 N WESTERN AVE
Mailing Address - Street 2:#319
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1820
Mailing Address - Country:US
Mailing Address - Phone:847-528-9880
Mailing Address - Fax:847-735-9611
Practice Address - Street 1:153 E LAUREL AVE
Practice Address - Street 2:#203
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-5407
Practice Address - Country:US
Practice Address - Phone:847-528-9880
Practice Address - Fax:847-735-9611
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist