MEDICARE: MISS MARIA WANDA OLSON PT SCS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1932047	OTHER	IL	BCBC

General Provider Information

NPI Number	:	1386753994
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS MARIA WANDA OLSON PT SCS

Provider Business Mailing Address
First Line	:	7885 LEE RD
Second Line	:
City	:	WATERMAN
State	:	IL
Zip	:	60556
Country	:	US
Telephone Number	:	815-264-9962
Fax Number	:

Provider Business Practice Location Address
First Line	:	125 N CEDAR ST
Second Line	:
City	:	WATERMAN
State	:	IL
Zip	:	60556
Country	:	US
Telephone Number	:	815-264-8600
Fax Number	:	815-264-8644

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/29/2006
Last Update Date	:	07/08/2007

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