Provider Demographics
NPI:1881771236
Name:OLSEN, GREGG A (PT)
Entity type:Individual
Prefix:MR
First Name:GREGG
Middle Name:A
Last Name:OLSEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5053 LA MART DR
Mailing Address - Street 2:STE 101
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-5993
Mailing Address - Country:US
Mailing Address - Phone:951-683-3309
Mailing Address - Fax:951-683-1886
Practice Address - Street 1:5053 LA MART DR
Practice Address - Street 2:STE 101
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-5993
Practice Address - Country:US
Practice Address - Phone:951-683-3309
Practice Address - Fax:951-683-1886
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT10713225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ29583ZMedicare ID - Type Unspecified