Provider Demographics
NPI:1124423645
Name:OLSEN, THOMAS STEPHEN (DPT)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:STEPHEN
Last Name:OLSEN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 GRANT ST
Mailing Address - Street 2:
Mailing Address - City:HARVARD
Mailing Address - State:IL
Mailing Address - Zip Code:60033-1821
Mailing Address - Country:US
Mailing Address - Phone:815-943-2961
Mailing Address - Fax:815-943-7789
Practice Address - Street 1:1301 N ALPINE RD # 201
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-2262
Practice Address - Country:US
Practice Address - Phone:779-696-0700
Practice Address - Fax:779-696-0710
Is Sole Proprietor?:No
Enumeration Date:2014-10-27
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070020877225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1124423645OtherBCBSWI
WI8177OtherMERCYCARE INSURANCE
WI1124423645Medicaid
IL214660-F400434743OtherIL MEDICARE