Provider Demographics
NPI:1972757425
Name:OLSON, STEPHANIE L
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:L
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 1:411 E. CONGRESS PARKWAY
Mailing Address - Street 2:SUITE B
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014
Mailing Address - Country:US
Mailing Address - Phone:815-459-3810
Mailing Address - Fax:
Practice Address - Street 1:411 E CONGRESS PKWY
Practice Address - Street 2:SUITE B
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-6247
Practice Address - Country:US
Practice Address - Phone:815-459-3810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-11
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.002469225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist