Healthcare Provider Details

I. General information

NPI: 1588158943
Provider Name (Legal Business Name): AMANDA RAE OLSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2018
Last Update Date: 05/02/2025
Certification Date: 05/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 MCKINLEY AVE
KELLOGG ID
83837-2693
US

IV. Provider business mailing address

204 OREGON ST
KELLOGG ID
83837-5018
US

V. Phone/Fax

Practice location:
  • Phone: 208-783-1267
  • Fax:
Mailing address:
  • Phone: 208-512-0733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number41308
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-37773
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: