Provider Demographics
NPI:1922500115
Name:OLSON, CLARICE
Entity Type:Individual
Prefix:
First Name:CLARICE
Middle Name:
Last Name:OLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 W BADGER CREEK TRL
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86005-8386
Mailing Address - Country:US
Mailing Address - Phone:409-599-1664
Mailing Address - Fax:
Practice Address - Street 1:1200 N BEAVER ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3118
Practice Address - Country:US
Practice Address - Phone:928-779-3366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-02
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13598A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant