Healthcare Provider Details

I. General information

NPI: 1902549942
Provider Name (Legal Business Name): MARIE OLSON LAC, BHP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2022
Last Update Date: 04/18/2022
Certification Date: 04/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4343 N 16TH ST
PHOENIX AZ
85016-5338
US

IV. Provider business mailing address

4343 N 16TH ST
PHOENIX AZ
85016-5338
US

V. Phone/Fax

Practice location:
  • Phone: 602-274-4343
  • Fax: 480-573-3592
Mailing address:
  • Phone: 602-274-4343
  • Fax: 480-573-3592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLAC-20446
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: