Healthcare Provider Details

I. General information

NPI: 1710458765
Provider Name (Legal Business Name): LENA M OLOFSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 12/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7550 N 16TH ST
PHOENIX AZ
85020-4618
US

IV. Provider business mailing address

3060 W LUCIA DR
PHOENIX AZ
85083-5878
US

V. Phone/Fax

Practice location:
  • Phone: 602-371-4100
  • Fax:
Mailing address:
  • Phone: 360-451-0021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number6581
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: