Basic Information
| Provider Information | |||||||||
| NPI: | 1003846866 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OLSON | ||||||||
| FirstName: | LIESL | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4515 MARSHA SHARP FWY | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794072520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067447223 | ||||||||
| FaxNumber: | 8067403325 | ||||||||
| Practice Location | |||||||||
| Address1: | 3223 S LOOP 289 | ||||||||
| Address2: | STE 101 | ||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794238312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067403342 | ||||||||
| FaxNumber: | 8067403325 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 04/02/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1063550 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 168331001 | 05 | TX | MEDICAID |