Healthcare Provider Details

I. General information

NPI: 1720053457
Provider Name (Legal Business Name): PETER OLSEN ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MOUNT HOLYOKE COLLEGE 50 COLLEGE STREET
SOUTH HADLEY MA
01075-1453
US

IV. Provider business mailing address

PO BOX 35 9 UNION AVE.
LAKE PLEASANT MA
01347-0035
US

V. Phone/Fax

Practice location:
  • Phone: 413-230-9883
  • Fax:
Mailing address:
  • Phone: 413-230-9883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1722
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: