Provider Demographics
NPI:1730291592
Name:OLSON, LISA SUZANNE MARIE (RPT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:SUZANNE MARIE
Last Name:OLSON
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1189 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-8123
Mailing Address - Country:US
Mailing Address - Phone:909-307-9121
Mailing Address - Fax:909-307-9161
Practice Address - Street 1:1189 W STATE ST
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-8123
Practice Address - Country:US
Practice Address - Phone:909-307-9121
Practice Address - Fax:909-307-9161
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21530225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ02588ZMedicare PIN