MEDICARE: TRACEY A OLSON LCSW

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	1041C0700X	Clinical Social Worker	149.014446	IL

General Provider Information

NPI Number	:	1407131139
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACEY A OLSON LCSW

Provider Business Mailing Address
First Line	:	PO BOX 310
Second Line	:
City	:	WESTERN SPRINGS
State	:	IL
Zip	:	60558-0310
Country	:	US
Telephone Number	:	708-567-3399
Fax Number	:

Provider Business Practice Location Address
First Line	:	4053 WOODLAND AVE
Second Line	:
City	:	WESTERN SPRINGS
State	:	IL
Zip	:	60558-1123
Country	:	US
Telephone Number	:	708-567-3399
Fax Number	:

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

Provider Enumeration Date	:	10/13/2011
Last Update Date	:	10/13/2011

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