Healthcare Provider Details

I. General information

NPI: 1962315697
Provider Name (Legal Business Name): REBECCA OLSON SLP - CCC, MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8518 22ND AVE
KENOSHA WI
53143-6455
US

IV. Provider business mailing address

3600 52ND ST
KENOSHA WI
53144-2664
US

V. Phone/Fax

Practice location:
  • Phone: 262-359-7198
  • Fax:
Mailing address:
  • Phone: 262-359-6300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number1001347420
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: