Provider Demographics
NPI:1083764492
Name:OLSEN, KRISTOPHER J (PHD)
Entity Type:Individual
Prefix:
First Name:KRISTOPHER
Middle Name:J
Last Name:OLSEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6767 N WICKHAM RD
Mailing Address - Street 2:SUITE 306
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-2031
Mailing Address - Country:US
Mailing Address - Phone:321-751-1925
Mailing Address - Fax:321-751-9261
Practice Address - Street 1:6767 N WICKHAM RD
Practice Address - Street 2:SUITE 306
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-2031
Practice Address - Country:US
Practice Address - Phone:321-751-1925
Practice Address - Fax:321-751-9261
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0004859103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59384Medicare ID - Type UnspecifiedMEDICARE