Provider Demographics
NPI:1336962349
Name:OLSON, SAMUEL RAY MCKAY
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:RAY MCKAY
Last Name:OLSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 FEDERAL ST
Mailing Address - Street 2:
Mailing Address - City:MILLIS
Mailing Address - State:MA
Mailing Address - Zip Code:02054-1459
Mailing Address - Country:US
Mailing Address - Phone:508-254-4701
Mailing Address - Fax:
Practice Address - Street 1:383 ELLIOT ST UNIT F
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02464-1126
Practice Address - Country:US
Practice Address - Phone:617-964-3332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-07
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16097225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist