Provider Demographics
NPI:1770832743
Name:OLSEN, RICHARD W (PTA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:W
Last Name:OLSEN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12513 SHENANDOAH TRL
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60585-4709
Mailing Address - Country:US
Mailing Address - Phone:815-782-7223
Mailing Address - Fax:
Practice Address - Street 1:1560 INDIAN TRAIL DR
Practice Address - Street 2:
Practice Address - City:RIVERWOODS
Practice Address - State:IL
Practice Address - Zip Code:60015-1627
Practice Address - Country:US
Practice Address - Phone:847-945-1917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-05
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.002229225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant