Provider Demographics
NPI:1588769137
Name:OLSSON, ROBERTA LEE (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:LEE
Last Name:OLSSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595 N COURTENAY PKWY
Mailing Address - Street 2:#203
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-4851
Mailing Address - Country:US
Mailing Address - Phone:321-453-8484
Mailing Address - Fax:321-453-8448
Practice Address - Street 1:595 N COURTENAY PKWY
Practice Address - Street 2:#203
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-4851
Practice Address - Country:US
Practice Address - Phone:321-453-8484
Practice Address - Fax:321-453-8448
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA2462235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist