Healthcare Provider Details

I. General information

NPI: 1891203576
Provider Name (Legal Business Name): SHANE OLSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2018
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14765 W MOUNTAIN VIEW BLVD STE 107
SURPRISE AZ
85374-2704
US

IV. Provider business mailing address

300 INTERNATIONAL PKWY STE 200
LAKE MARY FL
32746-5028
US

V. Phone/Fax

Practice location:
  • Phone: 602-649-0245
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-17-28181
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: