Provider Demographics
NPI:1902819774
Name:OLSON-KELLOGG, BECKY (PT)
Entity Type:Individual
Prefix:
First Name:BECKY
Middle Name:
Last Name:OLSON-KELLOGG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2820 AQUILA AVE S
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-2952
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3400 W 66TH ST
Practice Address - Street 2:SUITE 140
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2111
Practice Address - Country:US
Practice Address - Phone:952-345-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5101225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist