Healthcare Provider Details

I. General information

NPI: 1316068091
Provider Name (Legal Business Name): CATHY M OLSON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CATHY M SHEAHAN PTA

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3305C NORTH BALLARD RD.
APPLETON WI
54911-9001
US

IV. Provider business mailing address

N341 TAMARACK DR.
APPLETON WI
54915
US

V. Phone/Fax

Practice location:
  • Phone: 920-735-9234
  • Fax:
Mailing address:
  • Phone: 920-687-9074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number388-019
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: