=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558870071
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OLSON FAMILY THERAPY INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1451 RIMPAU AVE STE 212
-----------------------------------------------------
City | CORONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92879-7522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-444-1498
-----------------------------------------------------
Fax | 951-463-4043
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1451 RIMPAU AVE STE 212
-----------------------------------------------------
City | CORONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92879-7522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-444-1498
-----------------------------------------------------
Fax | 951-463-4043
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. TIMOTHY MICHAEL OLSON
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 951-444-1498
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 52764
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------