Provider Demographics
NPI:1043347131
Name:OLSEN, ROGER (LP, PSYD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:OLSEN
Suffix:
Gender:M
Credentials:LP, PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4660 SLATER RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-4047
Mailing Address - Country:US
Mailing Address - Phone:651-882-6299
Mailing Address - Fax:651-683-0057
Practice Address - Street 1:4660 SLATER RD
Practice Address - Street 2:SUITE 210
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-4047
Practice Address - Country:US
Practice Address - Phone:651-882-6299
Practice Address - Fax:651-683-0057
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN084673200Medicaid