Provider Demographics
NPI:1871712133
Name:OLSON, KATHRYN HERZOG
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:HERZOG
Last Name:OLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:
Other - Last Name:OLSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:11632 NORWAY CT
Mailing Address - Street 2:
Mailing Address - City:CHAMPLIN
Mailing Address - State:MN
Mailing Address - Zip Code:55316-2623
Mailing Address - Country:US
Mailing Address - Phone:763-427-7106
Mailing Address - Fax:
Practice Address - Street 1:7225 UNIVERSITY AVE NE
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-3134
Practice Address - Country:US
Practice Address - Phone:763-236-2150
Practice Address - Fax:763-236-2155
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN47332251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic