MEDICARE: MRS. LIESL LYNN OLSON PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	1063550	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003846866
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LIESL LYNN OLSON PT

Provider Business Mailing Address
First Line	:	4515 MARSHA SHARP FWY
Second Line	:
City	:	LUBBOCK
State	:	TX
Zip	:	79407-2520
Country	:	US
Telephone Number	:	806-744-7223
Fax Number	:	806-740-3325

Provider Business Practice Location Address
First Line	:	3223 S LOOP 289
Second Line	:	STE 101
City	:	LUBBOCK
State	:	TX
Zip	:	79423-8312
Country	:	US
Telephone Number	:	806-740-3342
Fax Number	:	806-740-3325

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/04/2006
Last Update Date	:	04/02/2012

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