Provider Demographics
NPI:1386753994
Name:OLSON, MARIA WANDA (PT SCS)
Entity type:Individual
Prefix:MISS
First Name:MARIA
Middle Name:WANDA
Last Name:OLSON
Suffix:
Gender:F
Credentials:PT SCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7885 LEE RD
Mailing Address - Street 2:
Mailing Address - City:WATERMAN
Mailing Address - State:IL
Mailing Address - Zip Code:60556
Mailing Address - Country:US
Mailing Address - Phone:815-264-9962
Mailing Address - Fax:
Practice Address - Street 1:125 N CEDAR ST
Practice Address - Street 2:
Practice Address - City:WATERMAN
Practice Address - State:IL
Practice Address - Zip Code:60556
Practice Address - Country:US
Practice Address - Phone:815-264-8600
Practice Address - Fax:815-264-8644
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1932047OtherBCBC
IL1932047OtherBCBC