Basic Information
Provider Information | |||||||||
NPI: | 1992887830 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | OLSEN | ||||||||
FirstName: | JULIE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PTA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | RAJALA | ||||||||
OtherFirstName: | JULIE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PTA | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 3100 SHORE DRIVE | ||||||||
Address2: |   | ||||||||
City: | MARINETTE | ||||||||
State: | WI | ||||||||
PostalCode: | 54143 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7157325111 | ||||||||
FaxNumber: | 7157320628 | ||||||||
Practice Location | |||||||||
Address1: | 3117 SHORE DRIVE | ||||||||
Address2: | SUITE 101 | ||||||||
City: | MARINETTE | ||||||||
State: | WI | ||||||||
PostalCode: | 54143 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7157325111 | ||||||||
FaxNumber: | 7157320628 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/19/2006 | ||||||||
LastUpdateDate: | 02/21/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 38919 | WI | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 40391600 | 05 | WI |   | MEDICAID |