Healthcare Provider Details

I. General information

NPI: 1912829250
Provider Name (Legal Business Name): MATTHEW B OLSEN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1777 E CLARK ST STE 210
POCATELLO ID
83201-3357
US

IV. Provider business mailing address

1777 E CLARK ST STE 210
POCATELLO ID
83201-3357
US

V. Phone/Fax

Practice location:
  • Phone: 208-203-2088
  • Fax:
Mailing address:
  • Phone: 208-203-2088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-36045
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: