Provider Demographics
NPI:1629323787
Name:OLSSON, TARA DODSON (DPT)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:DODSON
Last Name:OLSSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5301 PROVIDENCE RD
Mailing Address - Street 2:SUITE 80
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-4128
Mailing Address - Country:US
Mailing Address - Phone:757-467-4604
Mailing Address - Fax:757-467-2716
Practice Address - Street 1:1015 WEST 47TH STREET
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23508
Practice Address - Country:US
Practice Address - Phone:757-683-7041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305207441225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist