Provider Demographics
NPI:1114205960
Name:OLSON, CAMI ROSE (PTA)
Entity type:Individual
Prefix:
First Name:CAMI
Middle Name:ROSE
Last Name:OLSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:CAMI
Other - Middle Name:ROSE
Other - Last Name:KOZLOWSKI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:701 WILLOW STREET
Mailing Address - Street 2:
Mailing Address - City:PESHTIGO
Mailing Address - State:WI
Mailing Address - Zip Code:54157
Mailing Address - Country:US
Mailing Address - Phone:715-582-3962
Mailing Address - Fax:715-582-0803
Practice Address - Street 1:701 WILLOW STREET
Practice Address - Street 2:
Practice Address - City:PESHTIGO
Practice Address - State:WI
Practice Address - Zip Code:54157
Practice Address - Country:US
Practice Address - Phone:715-582-3962
Practice Address - Fax:715-582-0803
Is Sole Proprietor?:No
Enumeration Date:2011-07-28
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1790225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant