Provider Demographics
NPI:1164949376
Name:OLSON, RYAN
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
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 1:921 CREAMERY HILL RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62330-1216
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:921 CREAMERY HILL RD
Practice Address - Street 2:
Practice Address - City:DALLAS CITY
Practice Address - State:IL
Practice Address - Zip Code:62330-1216
Practice Address - Country:US
Practice Address - Phone:217-852-3204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-28
Last Update Date:2017-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1810042103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool