Provider Demographics
NPI:1003230269
Name:OLSON, LORI (IMH)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:OLSON
Suffix:
Gender:F
Credentials:IMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 TAMIAMI TRL
Mailing Address - Street 2:SUITE 204
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-8102
Mailing Address - Country:US
Mailing Address - Phone:941-629-0440
Mailing Address - Fax:
Practice Address - Street 1:3400 TAMIAMI TRL
Practice Address - Street 2:SUITE 204
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-8102
Practice Address - Country:US
Practice Address - Phone:941-629-0440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-09
Last Update Date:2014-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH 9229101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health