Healthcare Provider Details

I. General information

NPI: 1780448944
Provider Name (Legal Business Name): TODD ALLEN OLESON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2024
Last Update Date: 02/08/2024
Certification Date: 02/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2558 S BRENTWOOD BLVD
SAINT LOUIS MO
63144-2309
US

IV. Provider business mailing address

1958A WITHNELL AVE
SAINT LOUIS MO
63118-2517
US

V. Phone/Fax

Practice location:
  • Phone: 314-961-8940
  • Fax: 314-961-8969
Mailing address:
  • Phone: 314-420-5179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2023028468
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: