Healthcare Provider Details

I. General information

NPI: 1891552709
Provider Name (Legal Business Name): DEREK OLSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2024
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3322 STRAHAN PKWY
SHERIDAN WY
82801-9162
US

IV. Provider business mailing address

3322 STRAHAN PKWY
SHERIDAN WY
82801-9162
US

V. Phone/Fax

Practice location:
  • Phone: 307-672-2044
  • Fax:
Mailing address:
  • Phone: 619-683-3100
  • Fax: 307-672-2044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberPCSW-1281
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: