Healthcare Provider Details

I. General information

NPI: 1639526593
Provider Name (Legal Business Name): KATHY OLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2016
Last Update Date: 05/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2134 BARNETT AVENUE LITTLE HALL LOWER LEVEL
QUANTICO VA
22134
US

IV. Provider business mailing address

233 CHOPTANK RD
STAFFORD VA
22556-6451
US

V. Phone/Fax

Practice location:
  • Phone: 540-729-8794
  • Fax:
Mailing address:
  • Phone: 540-729-8794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904006548
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: