Healthcare Provider Details

I. General information

NPI: 1629323787
Provider Name (Legal Business Name): TARA DODSON OLSSON DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2012
Last Update Date: 01/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 WEST 47TH STREET
NORFOLK VA
23508
US

IV. Provider business mailing address

5301 PROVIDENCE RD SUITE 80
VIRGINIA BEACH VA
23464-4128
US

V. Phone/Fax

Practice location:
  • Phone: 757-683-7041
  • Fax:
Mailing address:
  • Phone: 757-467-4604
  • Fax: 757-467-2716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305207441
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: