Provider Demographics
NPI:1639510357
Name:OLSEN, TRAVIS LEE (ATC)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:LEE
Last Name:OLSEN
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 S ROWLEY ST
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:SD
Mailing Address - Zip Code:57301-4713
Mailing Address - Country:US
Mailing Address - Phone:605-933-1436
Mailing Address - Fax:
Practice Address - Street 1:414 E CLARK ST
Practice Address - Street 2:DAKOTA DOME #112
Practice Address - City:VERMILLION
Practice Address - State:SD
Practice Address - Zip Code:57069-2307
Practice Address - Country:US
Practice Address - Phone:605-677-5960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-10
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD390200000390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program