=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265915318
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELSEY ELIZABETH OLSEN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2018
-----------------------------------------------------
Last Update Date | 09/13/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 377 WESTRIDGE BLVD
-----------------------------------------------------
City | GREENWOOD
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46142-2137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-888-4948
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11085 LEXI LN
-----------------------------------------------------
City | FISHERS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46040-9130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-709-6660
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 46003459A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------