Provider Demographics
NPI:1992887830
Name:OLSEN, JULIE (PTA)
Entity type:Individual
Prefix:MS
First Name:JULIE
Middle Name:
Last Name:OLSEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MS
Other - First Name:JULIE
Other - Middle Name:
Other - Last Name:RAJALA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:3100 SHORE DRIVE
Mailing Address - Street 2:
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143
Mailing Address - Country:US
Mailing Address - Phone:715-732-5111
Mailing Address - Fax:715-732-0628
Practice Address - Street 1:3117 SHORE DRIVE
Practice Address - Street 2:SUITE 101
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143
Practice Address - Country:US
Practice Address - Phone:715-732-5111
Practice Address - Fax:715-732-0628
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI38919225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40391600Medicaid
WI40391600Medicaid