Provider Demographics
NPI:1073708061
Name:OLSON, KENNETH EDGAR
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:EDGAR
Last Name:OLSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4741 LAGO VISTA CIR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95129-1440
Mailing Address - Country:US
Mailing Address - Phone:408-243-5626
Mailing Address - Fax:
Practice Address - Street 1:4741 LAGO VISTA CIR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95129-1440
Practice Address - Country:US
Practice Address - Phone:408-243-5626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-12
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health