1295072577 NPI number — DIANA MARY GLICINI OLSEN P.T.

Table of content: DIANA MARY GLICINI OLSEN P.T. (NPI 1295072577)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295072577 NPI number — DIANA MARY GLICINI OLSEN P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OLSEN
Provider First Name:
DIANA
Provider Middle Name:
MARY GLICINI
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GLICINI
Provider Other First Name:
DIANA
Provider Other Middle Name:
MARY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1295072577
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/06/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
50 CORRINA LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALEM
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06420
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-574-5913
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
RED ROCK PHYSICAL THERAPY & BALANCE CENTER
Provider Second Line Business Practice Location Address:
744 MIDDLETOWN RD
Provider Business Practice Location Address City Name:
CALCHCESTOR
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06415
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-365-5514
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/07/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  014376 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)