Healthcare Provider Details

I. General information

NPI: 1730286121
Provider Name (Legal Business Name): DELORES HENDERSON-OLSON BS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LORI OLSON CADCIII

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 FIFTH AVE
SHELL LAKE WI
54871-0265
US

IV. Provider business mailing address

11 FIFTH AVE PO BOX 265
SHELL LAKE WI
54871-0265
US

V. Phone/Fax

Practice location:
  • Phone: 715-468-2841
  • Fax: 715-468-2374
Mailing address:
  • Phone: 715-468-2841
  • Fax: 715-468-2374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: