MEDICARE: MR. PAUL THEODORE OLSON LMSW

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	1041C0700X	Clinical Social Worker	6801090228	MI
2	101Y00000X	Counselor	L2003492	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	12511462	OTHER	MI	CAQH ID

General Provider Information

NPI Number	:	1336480854
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PAUL THEODORE OLSON LMSW

Provider Business Mailing Address
First Line	:	308 CLEVELAND AVE STE 302
Second Line	:
City	:	ISHPEMING
State	:	MI
Zip	:	49849-1842
Country	:	US
Telephone Number	:	906-290-7492
Fax Number	:

Provider Business Practice Location Address
First Line	:	308 CLEVELAND AVE STE 302
Second Line	:
City	:	ISHPEMING
State	:	MI
Zip	:	49849-1842
Country	:	US
Telephone Number	:	906-290-7492
Fax Number	:

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

Provider Enumeration Date	:	03/07/2013
Last Update Date	:	02/13/2023

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