Healthcare Provider Details

I. General information

NPI: 1508510678
Provider Name (Legal Business Name): AUTUMN OLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2022
Last Update Date: 03/28/2025
Certification Date: 03/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6366 TELEGRAPH RD
SAINT LOUIS MO
63129-4920
US

IV. Provider business mailing address

6366 TELEGRAPH RD
SAINT LOUIS MO
63129-4920
US

V. Phone/Fax

Practice location:
  • Phone: 920-857-9041
  • Fax: 920-857-3366
Mailing address:
  • Phone: 920-857-9041
  • Fax: 920-857-3366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-25-79662
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: