MEDICARE: LORI J OLSEN LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	LPC12825	AZ

General Provider Information

NPI Number	:	1083893911
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORI J OLSEN LPC

Provider Business Mailing Address
First Line	:	2916 E MINTON ST
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85213-1697
Country	:	US
Telephone Number	:	480-232-4302
Fax Number	:

Provider Business Practice Location Address
First Line	:	2158 N GILBERT RD
Second Line	:	SUITE 110
City	:	MESA
State	:	AZ
Zip	:	85203-2109
Country	:	US
Telephone Number	:	480-232-4302
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/28/2007
Last Update Date	:	10/28/2007

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