Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0200X | Occupational Therapist - Pediatrics | OT-513 | ID |
NPI | 1013029792 |
---|---|
Provider Name | Brian Lane Olson |
First Address | Idaho Falls, ID 83404-6154 |
Second Address | Idaho Falls, ID 83404-6154 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/08/2006 |
Last Update Date | 08/07/2007 |