Healthcare Provider Details

I. General information

NPI: 1902201551
Provider Name (Legal Business Name): MARY OLSON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2014
Last Update Date: 10/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1460 E VALLEY RD
BASALT CO
81621-8411
US

IV. Provider business mailing address

PO BOX 1115
BASALT CO
81621-1115
US

V. Phone/Fax

Practice location:
  • Phone: 970-925-5858
  • Fax: 888-391-5184
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number11919
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: