Healthcare Provider Details

I. General information

NPI: 1487884490
Provider Name (Legal Business Name): ERIN RAE OLSEN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2009
Last Update Date: 07/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6080 SOUTHWEST BLVD
BENBROOK TX
76109
US

IV. Provider business mailing address

6080 SOUTHWEST BLVD
BENBROOK TX
76109-3912
US

V. Phone/Fax

Practice location:
  • Phone: 817-731-9331
  • Fax: 817-731-9882
Mailing address:
  • Phone: 817-731-9331
  • Fax: 817-731-9882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2072156
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: