Provider Demographics
NPI:1053325175
Name:POWERS OLSON, SUSAN KAY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:KAY
Last Name:POWERS OLSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17508 MINNETONKA BLVD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-1007
Mailing Address - Country:US
Mailing Address - Phone:763-234-4876
Mailing Address - Fax:
Practice Address - Street 1:17508 MINNETONKA BLVD
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55345-1007
Practice Address - Country:US
Practice Address - Phone:763-234-4876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4504103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN365489300Medicaid
MN365489300Medicaid